Provider Demographics
NPI:1053922518
Name:JACKSON, ALEXANDREA J (LPC)
Entity type:Individual
Prefix:
First Name:ALEXANDREA
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 POPLAR DR
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9367
Mailing Address - Country:US
Mailing Address - Phone:804-733-6874
Mailing Address - Fax:804-518-1341
Practice Address - Street 1:350 POPLAR DR
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9367
Practice Address - Country:US
Practice Address - Phone:804-733-6874
Practice Address - Fax:804-518-1341
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701009711101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional