Healthcare Provider Details

I. General information

NPI: 1497649768
Provider Name (Legal Business Name): AMANDA LILLIAN JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2025
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 FRANKLIN SQUARE DR
ROSEDALE MD
21237-4458
US

IV. Provider business mailing address

2749 LENAPE WAY
EASTON PA
18040-7259
US

V. Phone/Fax

Practice location:
  • Phone: 908-310-3024
  • Fax:
Mailing address:
  • Phone: 908-310-3024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: