Healthcare Provider Details

I. General information

NPI: 1922615913
Provider Name (Legal Business Name): ANITA GAIL GRAVES-JACKSON CACI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2020
Last Update Date: 09/24/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2041 MARTIN LUTHER KING JR AVE SE FL 3
WASHINGTON DC
20020-7024
US

IV. Provider business mailing address

2041 MARTIN LUTHER KING JR AVE SE FL 3
WASHINGTON DC
20020-7024
US

V. Phone/Fax

Practice location:
  • Phone: 202-889-7900
  • Fax:
Mailing address:
  • Phone: 202-889-7900
  • Fax: 202-610-3095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCACI1116
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: