Provider Demographics
NPI:1326677287
Name:SIMON, JACKLYN (LPC, CSOTP, CCTP)
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:
Last Name:SIMON
Suffix:
Gender:F
Credentials:LPC, CSOTP, CCTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1499 LEW JONES RD
Mailing Address - Street 2:
Mailing Address - City:ALBERTA
Mailing Address - State:VA
Mailing Address - Zip Code:23821-2609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4901 E PATRICK HENRY HWY
Practice Address - Street 2:
Practice Address - City:BURKEVILLE
Practice Address - State:VA
Practice Address - Zip Code:23922-3454
Practice Address - Country:US
Practice Address - Phone:434-767-7801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-03
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701006044101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional