Provider Demographics
NPI:1346718228
Name:JACKSON, TAKIYA NACHELLE (MED)
Entity Type:Individual
Prefix:MRS
First Name:TAKIYA
Middle Name:NACHELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22204-5703
Mailing Address - Country:US
Mailing Address - Phone:703-228-6061
Mailing Address - Fax:
Practice Address - Street 1:2700 S LANG ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22206-3106
Practice Address - Country:US
Practice Address - Phone:703-228-6943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPPS-0606160103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool