Provider Demographics
NPI:1013798990
Name:JACKSON, ASHLEY (BA)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2631 MERRICK RD STE 202
Mailing Address - Street 2:
Mailing Address - City:BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-5784
Mailing Address - Country:US
Mailing Address - Phone:516-698-6995
Mailing Address - Fax:
Practice Address - Street 1:2444 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5808
Practice Address - Country:US
Practice Address - Phone:646-327-2723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst