Provider Demographics
NPI:1235123423
Name:JACKSON, GLORIA M (MD)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 OMNI BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4430
Mailing Address - Country:US
Mailing Address - Phone:757-232-8769
Mailing Address - Fax:757-232-8875
Practice Address - Street 1:222 GRAFTON DR
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:VA
Practice Address - Zip Code:23692-2152
Practice Address - Country:US
Practice Address - Phone:757-898-7737
Practice Address - Fax:757-898-8377
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101043609207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010158745Medicaid
P00291647OtherRR/MEDICARE
VA177855OtherANTHEM
VA007309T22Medicare ID - Type Unspecified
VAE86046Medicare UPIN