Healthcare Provider Details

I. General information

NPI: 1104072297
Provider Name (Legal Business Name): DERRELL GLENN JACKSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2008
Last Update Date: 05/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 CLAREMONT CT SUITE 100
COLONIAL HEIGHTS VA
23834-1765
US

IV. Provider business mailing address

205 MISTY RIDGE LN
SUFFOLK VA
23434-1516
US

V. Phone/Fax

Practice location:
  • Phone: 804-526-2121
  • Fax: 804-520-2617
Mailing address:
  • Phone: 757-406-7328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110002804
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110002804
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: