Provider Demographics
NPI:1659487809
Name:JACKSON, GINA LORI (RN)
Entity Type:Individual
Prefix:MS
First Name:GINA
Middle Name:LORI
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8616 SHADWELL DR
Mailing Address - Street 2:67
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22309-4634
Mailing Address - Country:US
Mailing Address - Phone:703-360-0338
Mailing Address - Fax:
Practice Address - Street 1:8119 HOLLAND RD
Practice Address - Street 2:PACT
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-3135
Practice Address - Country:US
Practice Address - Phone:703-799-2762
Practice Address - Fax:703-780-6928
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001086096163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult