Provider Demographics
NPI:1336172287
Name:JACKSON, SARAH C (LCSW, CSAC)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:C
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 BOULEVARD
Mailing Address - Street 2:SUITE A
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-1345
Mailing Address - Country:US
Mailing Address - Phone:804-520-7210
Mailing Address - Fax:804-520-8953
Practice Address - Street 1:3660 BOULEVARD
Practice Address - Street 2:SUITE A
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-1345
Practice Address - Country:US
Practice Address - Phone:804-520-7210
Practice Address - Fax:804-520-8953
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040031151041C0700X
VA0710000240101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA086361OtherSENTARA
VA4945280Medicaid
VA258581OtherANTHEM
VA086361OtherSENTARA
VA800001807Medicare ID - Type Unspecified