Provider Demographics
NPI:1063812451
Name:JACKSON, VANESSA (MS)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 PINE ST APT A102
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-1749
Mailing Address - Country:US
Mailing Address - Phone:267-819-9706
Mailing Address - Fax:
Practice Address - Street 1:4800 PINE ST APT A102
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19143-1749
Practice Address - Country:US
Practice Address - Phone:267-819-9706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH001472101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health