| Jackson Professional Serv Llc | |
|
420 Pine Ridge Rd Petersburg VA 23805-1320 | |
| (804) 714-5998 | |
| Not Available |
| Full Name | Jackson Professional Serv Llc |
|---|---|
| Speciality | Counselor - Addiction (substance Use Disorder) |
| Location | 420 Pine Ridge Rd, Petersburg, Virginia |
| Authorized Official Name and Position | Antoinita C Stokes (CONSULTANT) |
| Authorized Official Contact | 8046130087 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Jackson Professional Serv Llc 420 Pine Ridge Rd Petersburg VA 23805-1320 Ph: () - | Jackson Professional Serv Llc 420 Pine Ridge Rd Petersburg VA 23805-1320 Ph: (804) 714-5998 |
| NPI Number | 1922761352 |
|---|---|
| Provider Enumeration Date | 10/21/2021 |
| Last Update Date | 10/21/2021 |
| Certification Date | 10/21/2021 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1922761352 | NPI | - | NPPES |
| 0709024300 | Medicaid | VA | |
| 0733006270 | Other | VA | QMHP |
| 0733006270 | Medicaid | VA | |
| 0709024300 | Other | VA | SUBSTANCE ABUSE |
| 0732008263 | Other | VA | QMHP ADULT |
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