Provider Demographics
NPI:1841172533
Name:TERRY-JACKSON, REGINA
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:TERRY-JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 CAMPUS BLVD STE 320
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-2889
Mailing Address - Country:US
Mailing Address - Phone:540-536-5100
Mailing Address - Fax:
Practice Address - Street 1:97 ADMINISTRATIVE DR
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25404-6378
Practice Address - Country:US
Practice Address - Phone:304-350-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-23
Last Update Date:2025-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV123133363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily