Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | 0104556630 | VA |
NPI | 1699896100 |
---|---|
Provider Name | Dr. Brice Springer Jackson |
First Address | Charlottesville, VA 22903-6905 |
Second Address | Charlottesville, VA 22903-6905 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/04/2007 |
Last Update Date | 17/12/2012 |