Provider Demographics
NPI:1932885324
Name:JACKSON, VICTORIA (LCSWA)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSWA
Mailing Address - Street 1:7629 PURFOY RD # RF
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-9549
Mailing Address - Country:US
Mailing Address - Phone:919-285-4802
Mailing Address - Fax:
Practice Address - Street 1:7629 PURFOY RD
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-9549
Practice Address - Country:US
Practice Address - Phone:919-285-4802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-22
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP01880101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health