Provider Demographics
NPI:1164817987
Name:JACKSON, VALERIE P (LCSW)
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:P
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:VALERIE
Other - Middle Name:P
Other - Last Name:WING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3003 N CENTRAL AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2914
Mailing Address - Country:US
Mailing Address - Phone:602-685-6000
Mailing Address - Fax:602-302-7925
Practice Address - Street 1:6153 W OLIVE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-4564
Practice Address - Country:US
Practice Address - Phone:602-685-6000
Practice Address - Fax:623-937-2589
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-154351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ022866Medicaid
AZ022866Medicaid