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General NPI Number Information
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NPI Number | 1316967334
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Entity Type | Individual
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Provider Name | BONITA MARIE JACKSON-VERGARA LICENSED COUNSELOR
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Gender | Female
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Dates
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Enumeration Date | 07/20/2006
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Last Update Date | 10/13/2021
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Provider Practice Location Address
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Address Line | 1545 CROSSWAYS BLVD STE 250
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City | CHESAPEAKE
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State | VA
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Zip | 23320-0218
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Country | US
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Telephone | 704-804-9614
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Fax |
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Provider Business Mailing Address
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Address Line | 800 FOX RIDGE TRL
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City | CHESAPEAKE
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State | VA
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Zip | 23322-6506
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Country | US
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Telephone | 704-804-9614
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Fax | 757-312-9580
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 0718000386
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 0701005902
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License Number State | VA
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 4804
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License Number State | NC
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