Basic Information
| Provider Information | |||||||||
| NPI: | 1568421311 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | DENISE | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9007 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229069007 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 415 RAY C. HUNT DRIVE | ||||||||
| Address2: | STE 2200 | ||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229030001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349245700 | ||||||||
| FaxNumber: | 4349249616 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2006 | ||||||||
| LastUpdateDate: | 10/07/2014 | ||||||||
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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 | 363A00000X | 0110003442 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA9101300 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.