Provider Demographics
NPI:1639353592
Name:JACKSON, KEANDREA (MA)
Entity Type:Individual
Prefix:
First Name:KEANDREA
Middle Name:
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 1:113A S DAVIS AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-3447
Mailing Address - Country:US
Mailing Address - Phone:662-843-9445
Mailing Address - Fax:662-843-9447
Practice Address - Street 1:4780 I 55 N STE 105
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5542
Practice Address - Country:US
Practice Address - Phone:601-956-4816
Practice Address - Fax:601-956-4817
Is Sole Proprietor?:No
Enumeration Date:2007-12-27
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01670076Medicaid