Provider Demographics
NPI:1205515525
Name:JACKSON, AYANNA M
Entity type:Individual
Prefix:
First Name:AYANNA
Middle Name:M
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 1:111 KITFIELD RD
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-4210
Mailing Address - Country:US
Mailing Address - Phone:843-499-0516
Mailing Address - Fax:
Practice Address - Street 1:111 KITFIELD RD
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-4210
Practice Address - Country:US
Practice Address - Phone:843-499-0516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician