JACKSON PROFESSIONAL SERV LLC NPI 1922761352

NPI Information

NPI: 1922761352
Provider Name: JACKSON PROFESSIONAL SERV LLC
Classification: Counselor - 101YA0400X
Entity Type: Organization

Specialization: Addiction (Substance Use Disorder)

Address:
420 PINE RIDGE RD
PETERSBURG, VA
ZIP 23805
Phone: (804) 714-5998
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JACKSON PROFESSIONAL SERV LLC is an addiction (substance use disorder) counselor in Petersburg, VA. JACKSON PROFESSIONAL SERV LLC NPI is 1922761352. The provider is registered as an organization entity type and is a multiple single specialty group.

The provider's business location address is:

420 PINE RIDGE RD
PETERSBURG, VA
ZIP 23805-320
Phone: (804) 714-5998

The provider's authorized official is Antoinita C Stokes .
The authorized official title is Consultant and has the following contact phone number (804) 613-0087.

The enumeration date for this NPI number is 10/21/2021 and was last updated on 10/21/2021.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No.	Taxonomy Code	Taxonomy Clasification	Taxonomy Specialization	Primary
1	101YM0800X	Counselor	Mental Health	No
2	172V00000X	Community Health Worker		No
3	251S00000X	Community/Behavioral Health		No
4	261QM0855X	Clinic/Center	Adolescent and Children Mental Health	No
5	101YA0400X	Counselor	Addiction (Substance Use Disorder)	Yes

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No.	Other Provider Identifier	Other Provider Identifier Type	Other Provider Identifier State	Other Provider Identifier Issuer
1	0709024300	MEDICAID	VIRGINIA
2	0732008263	OTHER	VIRGINIA	QMHP ADULT
3	0733006270	OTHER	VIRGINIA	QMHP
4	0733006270	MEDICAID	VIRGINIA
5	0709024300	OTHER	VIRGINIA	SUBSTANCE ABUSE

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 5/5/2024

NPI Synchronization or Removal

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