Provider Demographics
NPI:1487651832
Name:JACKSON, GABRIELLE K (MD)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:K
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:PO BOX 11646
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24506-1646
Mailing Address - Country:US
Mailing Address - Phone:434-200-5895
Mailing Address - Fax:434-200-7529
Practice Address - Street 1:1901 TATE SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1109
Practice Address - Country:US
Practice Address - Phone:434-200-5895
Practice Address - Fax:434-200-7529
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101231613208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
010214769OtherVA PREMIER PROVIDER NUMBE
6122638001OtherCIGNA PROVIDER NUMBER
329076OtherSOUTHERN HEALTH PROVIDER
55500OtherSENTARA/OPTIMA PROVIDER N
B5342OtherMEDCOST PROVIDER NUMBER
186404OtherANTHEM PROVIDER NUMBER
20-3639329OtherPCHP PROVIDER NUMBER
203639329014OtherTRICARE PROVIDER NUMBER
VAP00475085OtherMEDICARE RAILROAD CARRIER
VA010214769Medicaid
203639329OtherUNITED HEALTHCARE PROVIDE
20-3639329OtherPCHP PROVIDER NUMBER
203639329OtherUNITED HEALTHCARE PROVIDE
329076OtherSOUTHERN HEALTH PROVIDER
203639329014OtherTRICARE PROVIDER NUMBER
VA021983C59Medicare PIN