| NPI | 1285152462 |
|---|---|
| Former Name | CHANTALLE J JACKSON |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110005852) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DC PA031383) |
| 363A00000X Physician Assistant (Licence: NY 022133) | |
| Enumeration Date | 2017-09-07 |
| Last Update Date | 2022-02-23 |