Provider Demographics
NPI:1013720614
Name:JACKSON, GREGORY ARTHUR
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:ARTHUR
Last Name:JACKSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 HOTCHKISS PL
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-8409
Mailing Address - Country:US
Mailing Address - Phone:540-479-7084
Mailing Address - Fax:
Practice Address - Street 1:2301 11TH ST NW APT 119
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20001-2245
Practice Address - Country:US
Practice Address - Phone:202-702-0794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-28
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant