Basic Information
| Provider Information | |||||||||
| NPI: | 1578644290 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 304 E LEIGH ST | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232191410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042257148 | ||||||||
| FaxNumber: | 8042257159 | ||||||||
| Practice Location | |||||||||
| Address1: | 304 E LEIGH ST | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232191410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042257148 | ||||||||
| FaxNumber: | 8042257159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 12/07/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0101030877 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0542922 | 01 | VA | ANTHEM/TRIGON/HMO/PPO/HEA | OTHER | 541588928 | 01 | VA | UNITEDHEALTHCARE | OTHER | 541588928 | 01 | VA | VA COORDINATED CARE | OTHER | 44130 | 01 | VA | SENTAR | OTHER | 541588928 | 01 | VA | SOUTHERHEALTH | OTHER | 541588928 | 01 | VA | VA PREMIER | OTHER | 541588928 | 01 | VA | PHCS | OTHER | 006044140 | 05 | VA | MEDICAID | 541588928 | 01 | VA | VIRGINIA HEALTH NETWORK | OTHER | C03251 | 01 | VA | MCR GROUP# | OTHER | 491268 | 01 | VA | AETNA/HMO/PPO | OTHER | 041765-00000 | 01 | VA | QUAL CHOICE | OTHER | 110054158 | 01 | VA | MCR RAILROAD | OTHER | 541588928/4971410007 | 01 | VA | CIGNA/HMO/PPO | OTHER |