Provider Demographics
NPI:1811091960
Name:JACKSON, PAMELA E (MD)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:E
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 1:4001 COLISEUM DR STE 300
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-6257
Mailing Address - Country:US
Mailing Address - Phone:757-827-2025
Mailing Address - Fax:757-275-9802
Practice Address - Street 1:4001 COLISEUM DR STE 300
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-6257
Practice Address - Country:US
Practice Address - Phone:757-827-2025
Practice Address - Fax:757-275-9802
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT035139207R00000X
VA0101271362207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
004235736OtherCOMMUNITY HEALTH NETWORK
3171723OtherAETNA
10Q3466OtherHEALTHNET
010035139CT03OtherANTHEM BLUE CROSS BLUE SH
P3597371OtherOXFORD
035139OtherCT CARE
CT004235736Medicaid
G26353Medicare ID - Type Unspecified
004235736OtherCOMMUNITY HEALTH NETWORK