Provider Demographics
NPI:1154201663
Name:JACKSON, PHARRODAH (LPN)
Entity type:Individual
Prefix:
First Name:PHARRODAH
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5113 SOUTHERN AVE APT 101
Mailing Address - Street 2:
Mailing Address - City:CAPITOL HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20743-5170
Mailing Address - Country:US
Mailing Address - Phone:240-714-8758
Mailing Address - Fax:
Practice Address - Street 1:7008 LITTLE RIVER TPKE STE G
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-3234
Practice Address - Country:US
Practice Address - Phone:833-357-0704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-04
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0002098056164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse