Provider Demographics
NPI:1447213996
Name:JACKSON, CHARLES BRADFORD (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:BRADFORD
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:251 BLISS LN
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:VA
Mailing Address - Zip Code:22066-3221
Mailing Address - Country:US
Mailing Address - Phone:703-759-4109
Mailing Address - Fax:866-300-6031
Practice Address - Street 1:2501 N GLEBE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22207-3558
Practice Address - Country:US
Practice Address - Phone:703-525-1911
Practice Address - Fax:866-300-6035
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-07
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101024618207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAB/C 36190001OtherBLUE CROSS
VA6459871Medicaid
VA148958700OtherWORKSMANS COMP
VACAREFIRST 3619001OtherCAREFIRST
VAB/C 36190001OtherBLUE CROSS
VAC88208Medicare UPIN