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General NPI Number Information
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NPI Number | 1356213169
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Entity Type | Individual
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Provider Name | JULIAN MYLES JACKSON
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Gender | Male
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Dates
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Enumeration Date | 09/22/2025
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Last Update Date | 09/22/2025
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Provider Practice Location Address
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Address Line | 1258 HOLLAND RD
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City | SUFFOLK
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State | VA
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Zip | 23434-6313
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Country | US
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Telephone | 877-848-9810
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Fax |
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Provider Business Mailing Address
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Address Line | 622 HORSE CAMP LN
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City | CHESAPEAKE
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State | VA
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Zip | 23323-5933
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Country | US
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Telephone | 302-494-5019
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Fax |
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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 |
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License Number State | VA
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