Provider Demographics
NPI:1013035294
Name:JACKSON, GLORIA L (CRNP)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:GLORIA
Other - Middle Name:L
Other - Last Name:PITTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:3400 CIVIC CENTER BLVD
Mailing Address - Street 2:PCAM 4 WEST
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:215-615-5858
Mailing Address - Fax:215-349-8144
Practice Address - Street 1:900 MEDICAL CENTER DR STE 200
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-2358
Practice Address - Country:US
Practice Address - Phone:856-557-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP007231363L00000X
NJ26NJ00058800363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner