Basic Information
| Provider Information | |||||||||
| NPI: | 1295123602 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | SARA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3264 ADVANCE MILLS RD | ||||||||
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| City: | RUCKERSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229683209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576514015 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 MEDICAL PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238059274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8047655000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2015 | ||||||||
| LastUpdateDate: | 01/07/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.