Provider Demographics
NPI:1932968542
Name:JACKSON, ASHLEIGH CAMILLE
Entity Type:Individual
Prefix:
First Name:ASHLEIGH
Middle Name:CAMILLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ASHLEIGH
Other - Middle Name:CAMILLE
Other - Last Name:SERRANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4518 BEECH RD STE 230
Mailing Address - Street 2:
Mailing Address - City:TEMPLE HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20748-6735
Mailing Address - Country:US
Mailing Address - Phone:703-586-8634
Mailing Address - Fax:
Practice Address - Street 1:4518 BEECH RD STE 230
Practice Address - Street 2:
Practice Address - City:TEMPLE HILLS
Practice Address - State:MD
Practice Address - Zip Code:20748-6735
Practice Address - Country:US
Practice Address - Phone:202-643-3592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704014596101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health