Provider Demographics
NPI:1699408682
Name:JACKSON, SIMAJAH DOMINIQUE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SIMAJAH
Middle Name:DOMINIQUE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14166 CUDDY LOOP APT 304
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-5995
Mailing Address - Country:US
Mailing Address - Phone:254-423-8065
Mailing Address - Fax:
Practice Address - Street 1:4410 SHIRLEY GATE RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-5518
Practice Address - Country:US
Practice Address - Phone:703-205-9452
Practice Address - Fax:703-653-1389
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040138541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical