Provider Demographics
NPI:1639415029
Name:JACKSON, ADEKANLA (MFT)
Entity Type:Individual
Prefix:MS
First Name:ADEKANLA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 BRANDYWINE BLVD
Mailing Address - Street 2:BELLEFONTE HEALING CENTER
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19809-2961
Mailing Address - Country:US
Mailing Address - Phone:302-932-4390
Mailing Address - Fax:
Practice Address - Street 1:811 BRANDYWINE BLVD
Practice Address - Street 2:BELLEFONTE HEALING CENTER
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19809-2961
Practice Address - Country:US
Practice Address - Phone:302-932-4390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-13
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEFA-0000002106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist