Provider Demographics
NPI:1275259376
Name:JACKSON, ASHLEY VICTORIA (LCSWA)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:VICTORIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4358
Mailing Address - Country:US
Mailing Address - Phone:704-874-9005
Mailing Address - Fax:
Practice Address - Street 1:1133 RATCHFORD DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:NC
Practice Address - Zip Code:28034-6500
Practice Address - Country:US
Practice Address - Phone:704-922-5285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-19
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0184111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical