Individual
THERESA G JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
3640 HIGH ST, SUITE 2A, PORTSMOUTH, VA 23707-3213
(757) 397-6930
(757) 397-4864
Mailing address
3640 HIGH ST, SUITE 2A, PORTSMOUTH, VA 23707-3213
(757) 397-6930
(757) 397-4864
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
0101050002
VA
208100000X
Physical Medicine & Rehabilitation Physician
0101050002
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
005602785
—
VA
01
—
080007399
MEDICARE INDIVIDUAL PROVIDER ID
VA
01
—
P00799688
RR MEICARE
VA
Enumeration date
07/20/2005
Last updated
07/24/2025
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