NPIMap

Individual provider Active NPI

Gloria M Jackson, M.D.

  • Family Medicine Physician
  • Grafton, VA
National Provider Identifier
1235123423
Registry record updated Feb 7, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
0101043609 Issued in VA
Practice address
222 Grafton Dr
Grafton, VA 23692-2152
Phone
(757) 898-7737
Fax
(757) 898-8377
NPI assigned
Sep 2, 2005
Last updated
Feb 7, 2020By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Feb 7, 2020

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 0101043609 VA Primary

Addresses

Primary practice location

222 Grafton Dr
Grafton, VA 23692-2152

Mailing address

860 Omni Blvd Ste 101
Newport News, VA 23606-4430
Phone (757) 232-8769

Other identifiers 3

IdentifierTypeStateIssuer
010158745MedicaidVA
177855OtherVAANTHEM
P00291647OtherRR/MEDICARE

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in VA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20050509000878 VA Practitioner - Family PracticePractitioner - Emergency Medicine 5698715639 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
University of Florida College of Medicine, 1986
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices

Practice addresses (Care Compare)

101 A York Crossing
Grafton, VA 23692
Phone (757) 898-7737

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
0101043609VAMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Tidewater Physicians Multispecialty Group PC CurrentSince Apr 1, 2005 Accepting new patients
Tidewater Physicians Multispecialty Group PC Family Medicine CurrentSince Apr 1, 2005 Accepting new patients
Mary Immaculate Hospital LLC Past Accepting new patients

Locations

101 York Crossing Rd
#A
Grafton, VA 23692
Phone (757) 898-7737

101A York Crossing Rd
Grafton, VA 23692
Phone (757) 898-7737

729 Thimble Shoals Blvd
Newport News, VA 23606
Phone (757) 874-1077

827 Diligence Dr
Ste 100
Newport News, VA 23606

860 Omni Blvd
Newport News, VA 23606
Phone (757) 369-8138

860 Omni Blvd
Ste 101
Newport News, VA 23606
Phone (757) 223-9794

860 Omni Blvd
Ste 303
Newport News, VA 23606
Phone (757) 232-8777

222 Grafton Dr
Yorktown, VA 23692
Phone (757) 898-7737

Interoperability endpoints

  • FHIR API: https://fhir4.healow.com/fhir/r4/BGFHDD

Organizations & group practices 3

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

Hospital & facility affiliations 5

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1125619200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1581033600000",
    "number": "1235123423",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "860 OMNI BLVD STE 101",
            "city": "NEWPORT NEWS",
            "state": "VA",
            "postal_code": "236064430",
            "telephone_number": "757-232-8769",
            "fax_number": "757-232-8875"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "222 GRAFTON DR",
            "city": "GRAFTON",
            "state": "VA",
            "postal_code": "236922152",
            "telephone_number": "757-898-7737",
            "fax_number": "757-898-8377"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "GLORIA",
        "middle_name": "M",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2005-09-02",
        "last_updated": "2020-02-07",
        "certification_date": "2020-02-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "VA",
            "license": "0101043609",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "010158745",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM",
            "identifier": "177855",
            "state": "VA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RR/MEDICARE",
            "identifier": "P00291647",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Grafton, VA

Sources for this page

Verify at the official NPI Registry.