Healthcare Provider Details

I. General information

NPI: 1194835694
Provider Name (Legal Business Name): PATRICIA A GARDNER-JACKSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 LAUREL ST
CULPEPER VA
22701-3910
US

IV. Provider business mailing address

6156 ADVANCE MILLS RD
RUCKERSVILLE VA
22968-1505
US

V. Phone/Fax

Practice location:
  • Phone: 540-825-5656
  • Fax: 540-825-1612
Mailing address:
  • Phone: 540-825-3100
  • Fax: 540-825-6245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904001420
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: