Provider Demographics
NPI:1073138285
Name:JACKSON, ANDRIA
Entity Type:Individual
Prefix:
First Name:ANDRIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9560 MARLBORO PIKE STE 105
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-3770
Mailing Address - Country:US
Mailing Address - Phone:301-535-7542
Mailing Address - Fax:
Practice Address - Street 1:9560 MARLBORO PIKE STE 105
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-3770
Practice Address - Country:US
Practice Address - Phone:301-535-7542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD4071201744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD407120OtherCOSMETOLOGY LICENCE