Basic Information
| Provider Information | |||||||||
| NPI: | 1457588600 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | HOPE | ||||||||
| MiddleName: | TIFFANY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2150 PENNSYLVANIA AVE NW STE 6B-412 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200373201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2027413225 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2150 PENNSYLVANIA AVE NW # 6B-402 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200373201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2027413364 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2009 | ||||||||
| LastUpdateDate: | 11/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | D84028 | MD | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208600000X | MD041042 | DC | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1457588600 | 05 | WA | MEDICAID |