Provider Demographics
NPI:1235771536
Name:JACKSON, VALENCIA
Entity Type:Individual
Prefix:
First Name:VALENCIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1343
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23661-0343
Mailing Address - Country:US
Mailing Address - Phone:757-254-8408
Mailing Address - Fax:
Practice Address - Street 1:914 THORNBRIAR CT
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23661-1026
Practice Address - Country:US
Practice Address - Phone:757-254-8409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001178399163WG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0600XNursing Service ProvidersRegistered NurseGerontology