Provider Demographics
NPI:1023552973
Name:JACKSON, AYSIA
Entity Type:Individual
Prefix:
First Name:AYSIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AYSIA
Other - Middle Name:
Other - Last Name:CAPERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:375 CONESTOGA WAY UNIT 2822
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89002-1102
Mailing Address - Country:US
Mailing Address - Phone:818-454-0644
Mailing Address - Fax:
Practice Address - Street 1:10775 PIONEER TRL STE 215
Practice Address - Street 2:
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-0234
Practice Address - Country:US
Practice Address - Phone:415-424-4266
Practice Address - Fax:415-520-6633
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-12
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVMI1264106H00000X
CALMFT120115106H00000X
CAIMF96253106H00000X
NV2941-R106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist