Individual
VENELLA JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
6755 N 83RD AVE APT 15103, GLENDALE, AZ 85303-2756
(623) 312-7768
(602) 279-1431
Mailing address
PO BOX 16906, PHOENIX, AZ 85011-6906
(602) 279-1427
(602) 279-1431
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
Primary
9262510
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
9262510
DCS/OLR LICENSING AUTHORITY
AZ
Enumeration date
09/26/2018
Last updated
09/26/2018
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