Active NPI
Mersedes S. Jackson, DDS
- Dentist
- Fort Gregg-Adams, VA
National Provider Identifier
1639664527
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 0401416895
- Practice address
- Kenner Army Health Clinic
700 24TH Street
Fort Gregg-Adams, VA 23801 - Phone
- (804) 734-5365
- NPI assigned
- Jun 25, 2018
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 0401416895 | VA | Primary |
Addresses
Primary practice location
Kenner Army Health Clinic
700 24TH Street
Fort Gregg-Adams, VA 23801
Mailing address
Kenner Army Health Center
700 24TH Street
Fort Gregg-Adams, VA 23801
Phone (804) 734-5365
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in ME
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20180809005881 | ME | Order and Referring Only - Dentist | 5698023430 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 0401416895 | VA | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1529884800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1730937600000",
"number": "1639664527",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "KENNER ARMY HEALTH CENTER",
"address_2": "700 24TH STREET",
"city": "FORT GREGG-ADAMS",
"state": "VA",
"postal_code": "23801",
"telephone_number": "804-734-5365"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "KENNER ARMY HEALTH CLINIC",
"address_2": "700 24TH STREET",
"city": "FORT GREGG-ADAMS",
"state": "VA",
"postal_code": "23801",
"telephone_number": "804-734-5365"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "MERSEDES",
"middle_name": "S.",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2018-06-25",
"last_updated": "2024-11-07",
"certification_date": "2024-11-04",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "VA",
"license": "0401416895",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Fort Gregg-Adams, VA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 7, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.