Healthcare Provider Details

I. General information

NPI: 1689592156
Provider Name (Legal Business Name): JAX PATHWAYS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1413 IDLEWOOD AVE
RICHMOND VA
23220-6003
US

IV. Provider business mailing address

1413 IDLEWOOD AVE
RICHMOND VA
23220-6003
US

V. Phone/Fax

Practice location:
  • Phone: 804-399-0677
  • Fax:
Mailing address:
  • Phone: 804-399-0677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. DECARDRA JACKSON
Title or Position: CEO
Credential:
Phone: 804-399-0677