Provider Demographics
NPI:1104072297
Name:JACKSON, DERRELL GLENN (PA-C)
Entity type:Individual
Prefix:
First Name:DERRELL
Middle Name:GLENN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 MISTY RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-1516
Mailing Address - Country:US
Mailing Address - Phone:757-406-7328
Mailing Address - Fax:
Practice Address - Street 1:436 CLAREMONT CT
Practice Address - Street 2:SUITE 100
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-1765
Practice Address - Country:US
Practice Address - Phone:804-526-2121
Practice Address - Fax:804-520-2617
Is Sole Proprietor?:No
Enumeration Date:2008-08-08
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002804363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1104072297Medicaid
VA10040880POtherOPTIMA
VAP00685057OtherRR MEDICARE
VA10040880POtherSENTARA HEALTHCARE
VAMC12468Medicare PIN
VAP00685057OtherRR MEDICARE