Provider Demographics
NPI:1376913111
Name:JACKSON, AMANDA MARIE
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:MAIRE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AMANDA MARIE SELLARS
Mailing Address - Street 1:24 GOLDLEAF FALLS AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-2957
Mailing Address - Country:US
Mailing Address - Phone:202-909-5016
Mailing Address - Fax:
Practice Address - Street 1:24 GOLDLEAF FALLS AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-2957
Practice Address - Country:US
Practice Address - Phone:202-909-5016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-06
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11782-C1041C0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health