Provider Demographics
NPI:1447804273
Name:JACKSON, AMANDA SUE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:SUE
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 1:8300 UTICA AVE STE 259
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3852
Mailing Address - Country:US
Mailing Address - Phone:909-906-1505
Mailing Address - Fax:
Practice Address - Street 1:8300 UTICA AVE STE 259
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3852
Practice Address - Country:US
Practice Address - Phone:909-906-1505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician