Healthcare Provider Details

I. General information

NPI: 1720121965
Provider Name (Legal Business Name): JAMES C JACKSON LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 12/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 PRESTON AVE
CHARLOTTESVILLE VA
22903-4420
US

IV. Provider business mailing address

71 TANBARK PLAZA
LOVINGSTON VA
22949
US

V. Phone/Fax

Practice location:
  • Phone: 434-792-1800
  • Fax:
Mailing address:
  • Phone: 434-263-4889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701001993
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: