Provider Demographics
NPI:1841987195
Name:GREEN-AUGUST, JACKIE ALICIA (CCHW)
Entity type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:ALICIA
Last Name:GREEN-AUGUST
Suffix:
Gender:F
Credentials:CCHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5963 NAMOZINE RD
Mailing Address - Street 2:
Mailing Address - City:CREWE
Mailing Address - State:VA
Mailing Address - Zip Code:23930-2734
Mailing Address - Country:US
Mailing Address - Phone:434-298-4012
Mailing Address - Fax:
Practice Address - Street 1:5963 NAMOZINE RD
Practice Address - Street 2:
Practice Address - City:CREWE
Practice Address - State:VA
Practice Address - Zip Code:23930-2734
Practice Address - Country:US
Practice Address - Phone:434-298-4012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA374J00000X
VA3465172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No374J00000XNursing Service Related ProvidersDoula