Healthcare Provider Details

I. General information

NPI: 1437709888
Provider Name (Legal Business Name): EMILY JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2019
Last Update Date: 09/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BUFORD RD STE 110
NORTH CHESTERFIELD VA
23235-5292
US

IV. Provider business mailing address

2106 FLOYD AVE
RICHMOND VA
23220-4532
US

V. Phone/Fax

Practice location:
  • Phone: 804-447-6382
  • Fax:
Mailing address:
  • Phone: 540-797-3675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701998652
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: