Provider Demographics
NPI:1982203139
Name:JACKSON, CENATA ALEXANDRIA
Entity Type:Individual
Prefix:MRS
First Name:CENATA
Middle Name:ALEXANDRIA
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 1:3990 RESTING PL
Mailing Address - Street 2:
Mailing Address - City:POWHATAN
Mailing Address - State:VA
Mailing Address - Zip Code:23139-6959
Mailing Address - Country:US
Mailing Address - Phone:910-641-1389
Mailing Address - Fax:
Practice Address - Street 1:7353 WHITEPINE RD BLDG G
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23237-2260
Practice Address - Country:US
Practice Address - Phone:910-641-1389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician