Healthcare Provider Details

I. General information

NPI: 1700439171
Provider Name (Legal Business Name): ANTOINETTE ROSA JACKSON (AZIZ) LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2019
Last Update Date: 07/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6122 RIDGE AVE
PHILADELPHIA PA
19128-1603
US

IV. Provider business mailing address

6014 CATHARINE ST # B
PHILADELPHIA PA
19143-2306
US

V. Phone/Fax

Practice location:
  • Phone: 215-487-1330
  • Fax:
Mailing address:
  • Phone: 215-432-8608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC009302
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: