Provider Demographics
NPI:1720718174
Name:JACKSON, SHAKINA VIRLEE
Entity Type:Individual
Prefix:
First Name:SHAKINA
Middle Name:VIRLEE
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 1:5810 KINGSTOWNE CTR STE 921
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22315-5732
Mailing Address - Country:US
Mailing Address - Phone:833-747-4222
Mailing Address - Fax:
Practice Address - Street 1:5810 KINGSTOWNE CTR STE 921
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22315-5732
Practice Address - Country:US
Practice Address - Phone:833-747-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician