Provider Demographics
NPI:1700439171
Name:JACKSON (AZIZ), ANTOINETTE ROSA (LPC)
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:ROSA
Last Name:JACKSON (AZIZ)
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6014 CATHARINE ST # B
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-2306
Mailing Address - Country:US
Mailing Address - Phone:215-432-8608
Mailing Address - Fax:
Practice Address - Street 1:6122 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-1603
Practice Address - Country:US
Practice Address - Phone:215-487-1330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC009302101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty