Provider Demographics
NPI:1922761352
Name:JACKSON PROFESSIONAL SERV LLC
Entity Type:Organization
Organization Name:JACKSON PROFESSIONAL SERV LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:ANTOINITA
Authorized Official - Middle Name:C
Authorized Official - Last Name:STOKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-613-0087
Mailing Address - Street 1:420 PINE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-1320
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:420 PINE RIDGE RD
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-1320
Practice Address - Country:US
Practice Address - Phone:804-714-5998
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0709024300Medicaid
VA0733006270OtherQMHP
VA0733006270Medicaid
VA0709024300OtherSUBSTANCE ABUSE
VA0732008263OtherQMHP ADULT