MEDICARE: TIMOTHY L JACKSON PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	0010-00505	NC
2	363A00000X	Physician Assistant	0110002037	VA

General Provider Information

NPI Number	:	1982623625
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY L JACKSON PA-C

Provider Business Mailing Address
First Line	:	801 YORK ST
Second Line	:
City	:	MANITOWOC
State	:	WI
Zip	:	54220-4630
Country	:	US
Telephone Number	:	920-663-9008
Fax Number	:	920-684-1439

Provider Business Practice Location Address
First Line	:	5249 PROVIDENCE RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-4201
Country	:	US
Telephone Number	:	757-467-3900
Fax Number	:	757-467-7800

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	06/03/2026

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