Individual
GRACIE JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
5830 STONE RIDGE DR, CENTREVILLE, VA 20120-2887
(718) 215-5311
(718) 865-5165
Mailing address
13800 COPPERMINE RD, HERNDON, VA 20171-6163
(718) 215-5311
(718) 865-5165
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
BACB1106900
VA
Other
Enumeration date
02/03/2025
Last updated
02/03/2025
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