1013035294 NPI number — GLORIA L JACKSON CRNP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013035294 NPI number — GLORIA L JACKSON CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
GLORIA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PITTS
Provider Other First Name:
GLORIA
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1013035294
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3400 CIVIC CENTER BLVD
Provider Second Line Business Mailing Address:
PCAM 4 WEST
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-615-5858
Provider Business Mailing Address Fax Number:
215-349-8144

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 MEDICAL CENTER DR STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEWELL
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08080-2358
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-557-7900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/27/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  SP007231 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 26NJ00058800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)