| Doctor Name: | DERRELL GLENN JACKSON |
| NPI Number: | 1104072297 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PA-C |
| License Number: | 0110002804 |
| Business Practice Address: | 436 Claremont Ct Suite 100 Colonial Heights, VA - 238341765 |
| Business Phone Number: | 8045262121 |
| Business Fax Number: | 8045202617 |
| Mailing Address: | 205 Misty Ridge Ln, SUFFOLK |
| State: | VA |
| Postal Code: | 234341516 |
| Phone Number: | 7574067328 |
| Fax Number: | |
| NPI Enumeration Date: | 08/08/2008 |
| NPI Last Update Date: | 05/26/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363AM0700X |
| License Number: | 0110002804 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | VA |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Physician Assistant |
| Taxonomy Specialization: | Medical |
| Taxonomy Definition: | |