Provider Demographics
NPI:1720121965
Name:JACKSON, JAMES C (LPC)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:C
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 TANBARK PLAZA
Mailing Address - Street 2:
Mailing Address - City:LOVINGSTON
Mailing Address - State:VA
Mailing Address - Zip Code:22949
Mailing Address - Country:US
Mailing Address - Phone:434-263-4889
Mailing Address - Fax:
Practice Address - Street 1:800 PRESTON AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-4420
Practice Address - Country:US
Practice Address - Phone:434-792-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701001993101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004945018Medicaid