Provider Demographics
NPI:1649084351
Name:JACKSON, GRACIE
Entity type:Individual
Prefix:
First Name:GRACIE
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 1:13800 COPPERMINE RD
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-6163
Mailing Address - Country:US
Mailing Address - Phone:718-215-5311
Mailing Address - Fax:718-865-5165
Practice Address - Street 1:5830 STONE RIDGE DR
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20120-2887
Practice Address - Country:US
Practice Address - Phone:718-215-5311
Practice Address - Fax:718-865-5165
Is Sole Proprietor?:No
Enumeration Date:2025-02-03
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VABACB1106900106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician