Provider Demographics
NPI:1518280734
Name:GARCIA JACKSON, VIANA (LMSW)
Entity Type:Individual
Prefix:
First Name:VIANA
Middle Name:
Last Name:GARCIA JACKSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:VIANA
Other - Middle Name:
Other - Last Name:GARCIA TORRES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:12371 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-8051
Mailing Address - Country:US
Mailing Address - Phone:787-564-7185
Mailing Address - Fax:
Practice Address - Street 1:2500 E VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-6037
Practice Address - Country:US
Practice Address - Phone:602-220-6022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-02
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
AZ13544104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health