Healthcare Provider Details

I. General information

NPI: 1871995803
Provider Name (Legal Business Name): CHARLES E. JACKSON FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2014
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8260 WILLOW OAKS CORPORATE DR STE 650
FAIRFAX VA
22031-4531
US

IV. Provider business mailing address

PO BOX 37174
BALTIMORE MD
21297-3174
US

V. Phone/Fax

Practice location:
  • Phone: 703-776-2000
  • Fax: 571-665-6797
Mailing address:
  • Phone: 571-423-5699
  • Fax: 571-423-5698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024178860
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: