Provider Demographics
NPI:1437709888
Name:JACKSON, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2106 FLOYD AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-4532
Mailing Address - Country:US
Mailing Address - Phone:540-797-3675
Mailing Address - Fax:
Practice Address - Street 1:101 BUFORD RD STE 110
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-5292
Practice Address - Country:US
Practice Address - Phone:804-447-6382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701998652101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional