DERRELL GLENN JACKSON PA-C NPI 1104072297

NPI Information

  • NPI: 1104072297
  • Provider Name: DERRELL GLENN JACKSON, PA-C
  • Classification: Physician Assistant - 363A00000X
  • Entity Type: Individual
  • Address: 436 CLAREMONT CT
    SUITE 100
    COLONIAL HEIGHTS, VA
    ZIP 23834
  • Phone: (804) 526-2121

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NPI Details

Derrell Glenn Jackson, PA-C is a physician assistant in Colonial Heights, VA. The provider is a physician assistant is a person who has successfully completed an accredited education program for physician assistant, is licensed by the state and is practicing within the scope of that license. Physician assistants are formally trained to perform many of the routine, time-consuming tasks a physician can do. In some states, they may prescribe medications. They take medical histories, perform physical exams, order lab tests and x-rays, and give inoculations. Most states require that they work under the supervision of a physician. Derrell Glenn Jackson, PA-C NPI is 1104072297. The provider is registered as an individual entity type.

The NPPES NPI record indicates the provider is a male.

The provider's business location address is:

436 CLAREMONT CT
SUITE 100
COLONIAL HEIGHTS, VA
ZIP 23834-765
Phone: (804) 526-2121
Fax: (804) 520-2617

The enumeration date for this NPI number is 8/8/2008 and was last updated on 5/26/2010.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1363AM0700XPhysician AssistantMedical0110002804VIRGINIANo
2363A00000XPhysician Assistant0110002804VIRGINIAYes

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
110040880POTHERVIRGINIAOPTIMA
2P00685057OTHERVIRGINIARR MEDICARE
31104072297MEDICAIDVIRGINIA
4MC12468MEDICARE PINVIRGINIA
510040880POTHERVIRGINIASENTARA HEALTHCARE
6MC12210MEDICARE PINVIRGINIA

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 11/21/2025

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