Provider Demographics
NPI:1194835694
Name:GARDNER-JACKSON, PATRICIA A (LCSW)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:A
Last Name:GARDNER-JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6156 ADVANCE MILLS RD
Mailing Address - Street 2:
Mailing Address - City:RUCKERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22968-1505
Mailing Address - Country:US
Mailing Address - Phone:540-825-3100
Mailing Address - Fax:540-825-6245
Practice Address - Street 1:650 LAUREL ST
Practice Address - Street 2:
Practice Address - City:CULPEPER
Practice Address - State:VA
Practice Address - Zip Code:22701-3910
Practice Address - Country:US
Practice Address - Phone:540-825-5656
Practice Address - Fax:540-825-1612
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040014201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4945361Medicaid
VA4945361Medicaid