Healthcare Provider Details

I. General information

NPI: 1700364908
Provider Name (Legal Business Name): LACREZIA JACKSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2018
Last Update Date: 07/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7025 HARBOUR VIEW BLVD STE 119
SUFFOLK VA
23435-2762
US

IV. Provider business mailing address

7025 HARBOUR VIEW BLVD STE 119
SUFFOLK VA
23435-2762
US

V. Phone/Fax

Practice location:
  • Phone: 757-966-2805
  • Fax: 757-673-6135
Mailing address:
  • Phone: 757-966-2805
  • Fax: 757-673-6135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904010568
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: