Healthcare Provider Details

I. General information

NPI: 1396888335
Provider Name (Legal Business Name): PATRICIA ANN JACKSON L.C.S.W
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 MINK PL
ABINGDON VA
24210-3426
US

IV. Provider business mailing address

510 CUMBERLAND ST. 4TH FLOOR, EXECUTIVE PLAZA
BRISTOL VA
24201
US

V. Phone/Fax

Practice location:
  • Phone: 276-628-8703
  • Fax: 276-628-8878
Mailing address:
  • Phone: 276-645-4758
  • Fax: 276-669-9093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904006464
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: