Provider Demographics
NPI:1790497410
Name:JACKSON, ALEXANDRIA H
Entity Type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:H
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 1:7767 OSWEGO RD
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-2322
Mailing Address - Country:US
Mailing Address - Phone:718-215-5311
Mailing Address - Fax:718-865-5165
Practice Address - Street 1:7767 OSWEGO RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-2322
Practice Address - Country:US
Practice Address - Phone:718-215-5311
Practice Address - Fax:718-865-5165
Is Sole Proprietor?:No
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician