Provider Demographics
NPI:1609631456
Name:KEITH-JACKSON, VALYN LEE (CSC-AD)
Entity Type:Individual
Prefix:
First Name:VALYN
Middle Name:LEE
Last Name:KEITH-JACKSON
Suffix:
Gender:F
Credentials:CSC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 224TH ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-1345
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1032 ANNAPOLIS RD
Practice Address - Street 2:
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054-1034
Practice Address - Country:US
Practice Address - Phone:443-440-5790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDSC3245101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)