Provider Demographics
NPI:1881192219
Name:JACKSON, ANDERIA
Entity Type:Individual
Prefix:
First Name:ANDERIA
Middle Name:
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 1:7416 DEEP RUN APT 1421
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48301-3841
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1410 S TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-0046
Practice Address - Country:US
Practice Address - Phone:248-451-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-31
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704265930163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health