Samuel Robert Jackson, PA

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

0110006058 Issued in VA

Practice address

1906 Belleview Ave SE
Roanoke, VA 24014-1838

Phone

(540) 981-7000

NPI assigned

Feb 2, 2018

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in VA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

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.

• Lake Spring Emergency Group, LLC

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  • Salem, VA
  • NPI 1215429600
  Medicare reassignment
• Emergency Coverage Services, PC

  • Nurse Practitioner
  • Lawrenceburg, TN
  • NPI 1053351593

  VA

  Medicare reassignment
• Emergency Coverage, LLC

  • Family Medicine Physician
  • Newport, TN
  • NPI 1427005008

  VA

  Medicare reassignment

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

{
    "created_epoch": "1517529600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1517529600000",
    "number": "1699274993",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "719 ARBUTUS AVE SE",
            "city": "ROANOKE",
            "state": "VA",
            "postal_code": "240142503",
            "telephone_number": "404-983-5673"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1906 BELLEVIEW AVE SE",
            "city": "ROANOKE",
            "state": "VA",
            "postal_code": "240141838",
            "telephone_number": "540-981-7000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "SAMUEL",
        "middle_name": "ROBERT",
        "name_prefix": "Mr.",
        "credential": "PA",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2018-02-02",
        "last_updated": "2018-02-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "VA",
            "license": "0110006058",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Bobbie Jackson, MSN, APRN, AGACNP-BC
• Brooke Ware Jackson
• John B Jackson
• Kaylyn A Jackson, PA
• Kyler Jackson
• Shamani Jackson
• Shana Jackson, LCSW
• Carol Jacobs, DPT
• Jonathan Dan Jacobs, APRN
• Tracey Jacobs

• Physician Assistant in Roanoke, VA
• Providers in Roanoke, VA by specialty
• Physician Assistant in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 2, 2018; 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.

Verify at the official NPI Registry.