Provider Demographics
NPI:1699249839
Name:JACKSON, KEIRA MICHELLE
Entity type:Individual
Prefix:
First Name:KEIRA
Middle Name:MICHELLE
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 1:8601 ROSE MALLOW DR APT 415
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-4025
Mailing Address - Country:US
Mailing Address - Phone:757-232-9100
Mailing Address - Fax:
Practice Address - Street 1:8601 ROSE MALLOW DR APT 415
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-4025
Practice Address - Country:US
Practice Address - Phone:757-232-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-21
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710103585101YA0400X
VA0704014248101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)