Basic Information
| Provider Information | |||||||||
| NPI: | 1487651832 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | GABRIELLE | ||||||||
| MiddleName: | K. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11889 | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245061889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349473944 | ||||||||
| FaxNumber: | 4345442316 | ||||||||
| Practice Location | |||||||||
| Address1: | 2215 LANDOVER PL | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245012115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349473944 | ||||||||
| FaxNumber: | 4345442316 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2005 | ||||||||
| LastUpdateDate: | 01/28/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101231613 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 203639329014 | 01 | TRICARE PROVIDER NUMBER | OTHER | 010214769 | 01 | VA PREMIER PROVIDER NUMBE | OTHER | 186404 | 01 | ANTHEM PROVIDER NUMBER | OTHER | 329076 | 01 | SOUTHERN HEALTH PROVIDER | OTHER | 55500 | 01 | SENTARA/OPTIMA PROVIDER N | OTHER | 20-3639329 | 01 | PCHP PROVIDER NUMBER | OTHER | P00475085 | 01 | VA | MEDICARE RAILROAD CARRIER | OTHER | 010214769 | 05 | VA | MEDICAID | 6122638001 | 01 | CIGNA PROVIDER NUMBER | OTHER | B5342 | 01 | MEDCOST PROVIDER NUMBER | OTHER | 203639329 | 01 | UNITED HEALTHCARE PROVIDE | OTHER |