Provider Demographics
NPI:1336914555
Name:JACKSON, MICHELLE L (DSW, LCSW)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DSW, LCSW
Other - Prefix:MRS
Other - First Name:MICHELLE
Other - Middle Name:L
Other - Last Name:JACKSON-WOODLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DSW
Mailing Address - Street 1:1525 HUGUENOT RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MIDLOTHIA
Mailing Address - State:VA
Mailing Address - Zip Code:23113
Mailing Address - Country:US
Mailing Address - Phone:804-924-7600
Mailing Address - Fax:
Practice Address - Street 1:2819 N. PARHAM RD
Practice Address - Street 2:SUITE 130
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23294
Practice Address - Country:US
Practice Address - Phone:804-924-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040159601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical