Provider Demographics
NPI:1730952763
Name:JACKSON, OLIVIA (SPECIALIST)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3730 CANDLERS MOUNTAIN RD # 1098
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-2228
Mailing Address - Country:US
Mailing Address - Phone:434-944-9955
Mailing Address - Fax:
Practice Address - Street 1:1200 HEATH AVE
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-1767
Practice Address - Country:US
Practice Address - Phone:434-944-9955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier