Provider Demographics
NPI:1376913111
Name:JACKSON, AMANDA MARIE
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:MAIRE
Other - Last Name:SELLARS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1504 BARKSDALE BLVD
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-4602
Mailing Address - Country:US
Mailing Address - Phone:318-222-4299
Mailing Address - Fax:
Practice Address - Street 1:1504 BARKSDALE BLVD
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-4602
Practice Address - Country:US
Practice Address - Phone:318-222-4299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health