Healthcare Provider Details

I. General information

NPI: 1659487809
Provider Name (Legal Business Name): GINA LORI JACKSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8119 HOLLAND RD PACT
ALEXANDRIA VA
22306-3135
US

IV. Provider business mailing address

8616 SHADWELL DR 67
ALEXANDRIA VA
22309-4634
US

V. Phone/Fax

Practice location:
  • Phone: 703-799-2762
  • Fax: 703-780-6928
Mailing address:
  • Phone: 703-360-0338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number0001086096
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: