Basic Information
| Provider Information | |||||||||
| NPI: | 1740583061 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REGION TEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 502 OLD LYNCHBURG RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229036550 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 502 OLD LYNCHBURG RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229036550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349721800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2010 | ||||||||
| LastUpdateDate: | 12/08/2010 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialTitleorPosition: | OUTPATIENT CLINICIAN | ||||||||
| AuthorizedOfficialTelephone: | 4349721800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 0701001993 | VA | Y | Agencies | Community/Behavioral Health |
No ID Information.