Provider Demographics
NPI:1952920449
Name:JACKSON, VONETTA BETHEA (LCSWA)
Entity type:Individual
Prefix:MRS
First Name:VONETTA
Middle Name:BETHEA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:MISS
Other - First Name:VONETTA
Other - Middle Name:CHAREECE
Other - Last Name:BETHEA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSW, LCSWA
Mailing Address - Street 1:1133 STRATHDON AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-0350
Mailing Address - Country:US
Mailing Address - Phone:910-261-9408
Mailing Address - Fax:
Practice Address - Street 1:391 WAGONER DRIVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303
Practice Address - Country:US
Practice Address - Phone:910-261-9408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCPO120311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical