Provider Demographics
NPI:1669962650
Name:JACKSON, AKUA (PHD)
Entity type:Individual
Prefix:DR
First Name:AKUA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5306 NC HIGHWAY 55 STE 105
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-7812
Mailing Address - Country:US
Mailing Address - Phone:919-457-1517
Mailing Address - Fax:
Practice Address - Street 1:2634 DURHAM CHAPEL HILL BLVD STE 220
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-2877
Practice Address - Country:US
Practice Address - Phone:919-288-8993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-15
Last Update Date:2024-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
NC5720103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No172V00000XOther Service ProvidersCommunity Health Worker