Provider Demographics
NPI:1306509724
Name:JACKSON, VALECIA (CSAC)
Entity type:Individual
Prefix:
First Name:VALECIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 PINE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-1320
Mailing Address - Country:US
Mailing Address - Phone:804-714-5998
Mailing Address - Fax:
Practice Address - Street 1:420 PINE RIDGE RD
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-1320
Practice Address - Country:US
Practice Address - Phone:804-714-5998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101YM0800X
VA0709024300101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0709024300Medicaid
VA0709024300OtherSUBSTANCE ABUSE