Derrell Glenn Jackson, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

0110002804 Issued in VA

Practice address

436 Claremont CT
Suite 100
Colonial Heights, VA 23834-1765

Phone

(804) 526-2121

Fax

(804) 520-2617

NPI assigned

Aug 8, 2008

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 4

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Petersburg Clinic Company LLC

  • Family Medicine Physician
  • Petersburg, VA
  • NPI 1881643617
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1218153600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1274832000000",
    "number": "1104072297",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "205 MISTY RIDGE LN",
            "city": "SUFFOLK",
            "state": "VA",
            "postal_code": "234341516",
            "telephone_number": "757-406-7328"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "436 CLAREMONT CT",
            "address_2": "SUITE 100",
            "city": "COLONIAL HEIGHTS",
            "state": "VA",
            "postal_code": "238341765",
            "telephone_number": "804-526-2121",
            "fax_number": "804-520-2617"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "DERRELL",
        "middle_name": "GLENN",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2008-08-08",
        "last_updated": "2010-05-26",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "VA",
            "license": "0110002804",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "VA",
            "license": "0110002804",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1104072297",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "OPTIMA",
            "identifier": "10040880P",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RR MEDICARE",
            "identifier": "P00685057",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "SENTARA HEALTHCARE",
            "identifier": "10040880P",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Infant Jesus Childrens Clinic PLC
• Talha Iqbal, DDS
• Irshad Ahmed MD PC
• Yorckay Chang Ishizawar, M.D.
• Claire Emma Jackson
• Rebecca Jackson, M.S., CCC-SLP
• Sarah C Jackson, LCSW, CSAC
• Shavonne Jackson, NP
• Tonya Tonique Jackson, APRN
• Harvinder S Jagait, MD

• Physician Assistant in Colonial Heights, VA
• Providers in Colonial Heights, VA by specialty
• Physician Assistant in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 26, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.