Provider Demographics
NPI:1346532223
Name:JACKSON, VANESSA JANE (MSW)
Entity Type:Individual
Prefix:MS
First Name:VANESSA
Middle Name:JANE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 BRADDOCK ST SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-4617
Mailing Address - Country:US
Mailing Address - Phone:404-755-4988
Mailing Address - Fax:404-755-5633
Practice Address - Street 1:833 BRADDOCK ST SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310-4617
Practice Address - Country:US
Practice Address - Phone:404-755-4988
Practice Address - Fax:404-755-5633
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-10
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA25621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical