Provider Demographics
NPI:1245213354
Name:JACKSON, GLORIA J (FNP)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2106
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-2106
Mailing Address - Country:US
Mailing Address - Phone:601-703-4282
Mailing Address - Fax:601-703-4597
Practice Address - Street 1:9097 COLLINSVILLE RD
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:MS
Practice Address - Zip Code:39325-9779
Practice Address - Country:US
Practice Address - Phone:601-626-8874
Practice Address - Fax:601-626-8592
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR715654363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
730-15594OtherBLUE CROSS OF AL
MS09573377Medicaid
AL891010060Medicaid
Q49469Medicare UPIN
500001935Medicare ID - Type Unspecified