Provider Demographics
NPI:1700364908
Name:JACKSON, LACREZIA (LCSW)
Entity Type:Individual
Prefix:
First Name:LACREZIA
Middle Name:
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 1:7025 HARBOUR VIEW BLVD STE 119
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-2762
Mailing Address - Country:US
Mailing Address - Phone:757-966-2805
Mailing Address - Fax:757-673-6135
Practice Address - Street 1:7025 HARBOUR VIEW BLVD STE 119
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-2762
Practice Address - Country:US
Practice Address - Phone:757-966-2805
Practice Address - Fax:757-673-6135
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
VA09040105681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical