Provider Demographics
NPI:1144860255
Name:JACKSON, JUDY
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 346
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:VA
Mailing Address - Zip Code:23040-0346
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29 MORRIS DR
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:VA
Practice Address - Zip Code:23040-2625
Practice Address - Country:US
Practice Address - Phone:804-627-3460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle