Provider Demographics
NPI:1659111342
Name:JACKSON, VICTORIA (LCSW)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 LAS BRISAS DR
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-5273
Mailing Address - Country:US
Mailing Address - Phone:773-746-3867
Mailing Address - Fax:
Practice Address - Street 1:101 KING PLZ STE D
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:TX
Practice Address - Zip Code:75428-3734
Practice Address - Country:US
Practice Address - Phone:773-746-3867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1034341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical