Provider Demographics
NPI:1225371651
Name:JACKSON, ANDREA LATRELL (MA)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:LATRELL
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10610 N 30TH ST
Mailing Address - Street 2:APT. 46H
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-6458
Mailing Address - Country:US
Mailing Address - Phone:813-997-6288
Mailing Address - Fax:
Practice Address - Street 1:10610 N 30TH ST
Practice Address - Street 2:APT. 46H
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-6458
Practice Address - Country:US
Practice Address - Phone:813-997-6288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-04
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker