Provider Demographics
NPI:1457622656
Name:JACKSON, ANDREA JASMINE
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:JASMINE
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:P O BOX 770173
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177
Mailing Address - Country:US
Mailing Address - Phone:305-846-9807
Mailing Address - Fax:305-846-9711
Practice Address - Street 1:7715 NW 48 ST
Practice Address - Street 2:SUITE B360
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33166
Practice Address - Country:US
Practice Address - Phone:305-846-9807
Practice Address - Fax:305-846-9711
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst