Basic Information
| Provider Information | |||||||||
| NPI: | 1588204721 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | RICHARDSON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9101 STONY POINT PKWY APT 1140 | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232352059 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 10438 IRON BRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | CHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238311427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8047961518 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2020 | ||||||||
| LastUpdateDate: | 09/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305213383 | VA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | P20566 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.