Provider Demographics
NPI:1548345325
Name:JACKSON, EUGENE F
Entity type:Individual
Prefix:
First Name:EUGENE
Middle Name:F
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 BRIDGE ST
Mailing Address - Street 2:STE 300
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-1222
Mailing Address - Country:US
Mailing Address - Phone:434-793-4711
Mailing Address - Fax:434-797-2514
Practice Address - Street 1:125 EXECUTIVE DR
Practice Address - Street 2:SUITE A
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-4155
Practice Address - Country:US
Practice Address - Phone:434-793-4711
Practice Address - Fax:434-797-2514
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840446363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA970000592Medicare PIN