Provider Demographics
NPI:1578041752
Name:JACKSON, JANAE (LMHP, LCSW)
Entity Type:Individual
Prefix:
First Name:JANAE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMHP, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18518 QUANTICO GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:TRIANGLE
Mailing Address - State:VA
Mailing Address - Zip Code:22172-1773
Mailing Address - Country:US
Mailing Address - Phone:571-641-9745
Mailing Address - Fax:
Practice Address - Street 1:10715 SPOTSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-2674
Practice Address - Country:US
Practice Address - Phone:540-339-3640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040106081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical