Provider Demographics
NPI:1639855836
Name:JACKSON, LAVILA D
Entity type:Individual
Prefix:
First Name:LAVILA
Middle Name:D
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 1:6246 HEATHER GLEN WAY
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21029-1175
Mailing Address - Country:US
Mailing Address - Phone:443-852-7036
Mailing Address - Fax:
Practice Address - Street 1:7090 SAMUEL MORSE DR STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-3444
Practice Address - Country:US
Practice Address - Phone:443-852-7036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-23
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator