Provider Demographics
NPI:1932885324
Name:JACKSON, VICTORIA (LCSWA)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:SHAILISA
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSWA
Mailing Address - Street 1:7629 PURFOY RD # RF
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-9549
Mailing Address - Country:US
Mailing Address - Phone:919-285-4802
Mailing Address - Fax:
Practice Address - Street 1:208 MALLOY ST STE B
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-4478
Practice Address - Country:US
Practice Address - Phone:984-520-6080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-22
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0188901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical