Provider Demographics
NPI:1710951793
Name:WHITE, JACKIE JEANNE (BSN, EDD)
Entity Type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:JEANNE
Last Name:WHITE
Suffix:
Gender:F
Credentials:BSN, EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4815 WATERFRONT DRIVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23508-2054
Mailing Address - Country:US
Mailing Address - Phone:757-440-0437
Mailing Address - Fax:
Practice Address - Street 1:620 JOHN PAUL JONES CIRCLE
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708-2197
Practice Address - Country:US
Practice Address - Phone:757-953-5282
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701002171101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional