Provider Demographics
NPI:1366729493
Name:JACKSON, DIANE (LCSW)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:SALTZBURG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:9416 CREEK SUMMIT CIR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23235-4277
Mailing Address - Country:US
Mailing Address - Phone:804-819-4000
Mailing Address - Fax:804-819-5221
Practice Address - Street 1:9416 CREEK SUMMIT CIR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23235-4277
Practice Address - Country:US
Practice Address - Phone:804-819-4000
Practice Address - Fax:804-819-5221
Is Sole Proprietor?:No
Enumeration Date:2011-11-03
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040076971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical