Provider Demographics
NPI:1396563102
Name:JACKSON, HALLIE
Entity type:Individual
Prefix:
First Name:HALLIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4151 MONUMENT HILL WAY APT 15206
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-8321
Mailing Address - Country:US
Mailing Address - Phone:865-387-0690
Mailing Address - Fax:
Practice Address - Street 1:200 LITTLE FALLS ST STE 306
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-4302
Practice Address - Country:US
Practice Address - Phone:703-231-7991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker