Provider Demographics
NPI:1427533363
Name:JACKSON, VENELLA
Entity type:Individual
Prefix:
First Name:VENELLA
Middle Name:
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:PO BOX 16906
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85011-6906
Mailing Address - Country:US
Mailing Address - Phone:602-279-1427
Mailing Address - Fax:602-279-1431
Practice Address - Street 1:6755 N 83RD AVE APT 15103
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85303-2756
Practice Address - Country:US
Practice Address - Phone:623-312-7768
Practice Address - Fax:602-279-1431
Is Sole Proprietor?:No
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9262510104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ9262510OtherDCS/OLR LICENSING AUTHORITY