Provider Demographics
NPI:1871995803
Name:JACKSON, CHARLES E (FNP-C)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:E
Last Name:JACKSON
Suffix:
Gender:M
Credentials:FNP-C
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 37174
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3174
Mailing Address - Country:US
Mailing Address - Phone:571-423-5699
Mailing Address - Fax:571-423-5698
Practice Address - Street 1:4600 LANGSTON BLVD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22207
Practice Address - Country:US
Practice Address - Phone:571-492-3080
Practice Address - Fax:571-491-3081
Is Sole Proprietor?:No
Enumeration Date:2014-09-22
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5007190363LF0000X
DCRN1049831363LF0000X
VA0024178860363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily