Provider Demographics
NPI:1356144513
Name:JACKSON, JOHNASIA
Entity type:Individual
Prefix:
First Name:JOHNASIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7569 HUNTERS RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29420-8586
Mailing Address - Country:US
Mailing Address - Phone:803-378-2411
Mailing Address - Fax:
Practice Address - Street 1:7569 HUNTERS RIDGE LN
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29420-8586
Practice Address - Country:US
Practice Address - Phone:803-378-2411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst