MEDICARE: DR. CHARLES BRADFORD JACKSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	0101024618	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	B/C 36190001	OTHER	VA	BLUE CROSS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	148958700	OTHER	VA	WORKSMANS COMP
4	CAREFIRST 3619001	OTHER	VA	CAREFIRST

General Provider Information

NPI Number	:	1447213996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES BRADFORD JACKSON MD

Provider Business Mailing Address
First Line	:	251 BLISS LN
Second Line	:
City	:	GREAT FALLS
State	:	VA
Zip	:	22066-3221
Country	:	US
Telephone Number	:	703-759-4109
Fax Number	:	866-300-6031

Provider Business Practice Location Address
First Line	:	2501 N GLEBE RD
Second Line	:	SUITE 201
City	:	ARLINGTON
State	:	VA
Zip	:	22207-3558
Country	:	US
Telephone Number	:	703-525-1911
Fax Number	:	866-300-6035

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/07/2006
Last Update Date	:	12/08/2011

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