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General NPI Number Information
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NPI Number | 1447213996
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Entity Type | Individual
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Provider Name | CHARLES BRADFORD JACKSON MD
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Gender | Male
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Dates
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Enumeration Date | 04/07/2006
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Last Update Date | 12/08/2011
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Provider Practice Location Address
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Address Line | 2501 N GLEBE RD SUITE 201
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City | ARLINGTON
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State | VA
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Zip | 22207-3558
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Country | US
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Telephone | 703-525-1911
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Fax | 866-300-6035
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Provider Business Mailing Address
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Address Line | 251 BLISS LN
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City | GREAT FALLS
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State | VA
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Zip | 22066-3221
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Country | US
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Telephone | 703-759-4109
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Fax | 866-300-6031
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207XX0005X
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Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
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License Number | 0101024618
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License Number State | VA
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