Provider Demographics
NPI:1417634841
Name:JACKSON, ASHLEY STARR
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:STARR
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:STARR
Other - Last Name:MITRICKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:275 LAURENCE PKWY # B
Mailing Address - Street 2:
Mailing Address - City:LAURENCE HARBOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08879-2766
Mailing Address - Country:US
Mailing Address - Phone:908-451-4120
Mailing Address - Fax:
Practice Address - Street 1:111 STATE ROUTE 35
Practice Address - Street 2:
Practice Address - City:CLIFFWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07721-1512
Practice Address - Country:US
Practice Address - Phone:732-812-5489
Practice Address - Fax:732-566-1937
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-28
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone