Provider Demographics
NPI:1457118515
Name:JACKSON, ALEXIS
Entity Type:Individual
Prefix:
First Name:ALEXIS
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 1:425 COKESBURY RD
Mailing Address - Street 2:
Mailing Address - City:PORT DEPOSIT
Mailing Address - State:MD
Mailing Address - Zip Code:21904-1729
Mailing Address - Country:US
Mailing Address - Phone:301-437-8557
Mailing Address - Fax:
Practice Address - Street 1:1301 LENFANT SQ SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-6724
Practice Address - Country:US
Practice Address - Phone:202-269-2404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator