Provider Demographics
NPI:1790296937
Name:JACKSON, ZENA AUSET ZECHARIAH DIANE (CADC CCAR, CRPA)
Entity Type:Individual
Prefix:MS
First Name:ZENA AUSET ZECHARIAH
Middle Name:DIANE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CADC CCAR, CRPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 LOUCKS RD # 1008
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17404-2201
Mailing Address - Country:US
Mailing Address - Phone:631-530-7877
Mailing Address - Fax:
Practice Address - Street 1:104 DAVIES DR
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-8605
Practice Address - Country:US
Practice Address - Phone:717-840-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-16
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA19676101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)