Provider Demographics
NPI:1265785786
Name:JACKSON, GINA DIANE (PA-C)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:DIANE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8109 TIS WELL DRIVE
Mailing Address - Street 2:SUITE 511
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22306
Mailing Address - Country:US
Mailing Address - Phone:703-799-9500
Mailing Address - Fax:703-799-9502
Practice Address - Street 1:8109 TIS WELL DRIVE
Practice Address - Street 2:SUITE 511
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306
Practice Address - Country:US
Practice Address - Phone:703-799-9500
Practice Address - Fax:703-799-9502
Is Sole Proprietor?:No
Enumeration Date:2012-10-22
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0110-004038363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant