Provider Demographics
NPI:1639195407
Name:JACKSON, BERNICE D (MD)
Entity Type:Individual
Prefix:DR
First Name:BERNICE
Middle Name:D
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 1:15009 NOTLEY RD
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20905-7438
Mailing Address - Country:US
Mailing Address - Phone:202-269-9429
Mailing Address - Fax:202-269-9271
Practice Address - Street 1:1160 VARNUM ST NE
Practice Address - Street 2:SUITE 314
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2107
Practice Address - Country:US
Practice Address - Phone:202-269-9249
Practice Address - Fax:202-269-9271
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD17118207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC027063100Medicaid
DC579232OtherALLIANCE
DC6631 0001OtherBC BS DC
DCAETNAOther2005550
MD63833701OtherBCBS MD
DC6631 0001OtherBC BS DC
DCF48124Medicare UPIN