Provider Demographics
NPI:1144466368
Name:HORACE J JACKSON MD PC
Entity type:Organization
Organization Name:HORACE J JACKSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HORACE
Authorized Official - Middle Name:J
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-788-0556
Mailing Address - Street 1:464 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:VA
Mailing Address - Zip Code:22572
Mailing Address - Country:US
Mailing Address - Phone:804-788-0556
Mailing Address - Fax:
Practice Address - Street 1:464 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:VA
Practice Address - Zip Code:22572
Practice Address - Country:US
Practice Address - Phone:804-788-0556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-17
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006O49656Medicaid
VA006954OtherANTHEM
VAB09238Medicare UPIN
VA006954OtherANTHEM