Provider Demographics
NPI:1366684839
Name:JACKSON, DONALD WAYNE (LPC)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:WAYNE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3434 MOUNT BURNSIDE WAY
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-1013
Mailing Address - Country:US
Mailing Address - Phone:703-490-8250
Mailing Address - Fax:703-490-8282
Practice Address - Street 1:3434 MOUNT BURNSIDE WAY
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-1013
Practice Address - Country:US
Practice Address - Phone:703-490-8250
Practice Address - Fax:703-490-8282
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC171M00000X171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator