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General NPI Number Information
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NPI Number | 1891342804
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Entity Type | Individual
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Provider Name | ANNA JACKSON
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Gender | Female
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Dates
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Enumeration Date | 08/23/2019
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Last Update Date | 12/12/2024
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Provider Practice Location Address
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Address Line | 112 N BROAD ST
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City | PHILADELPHIA
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State | PA
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Zip | 19102-1512
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Country | US
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Telephone | 215-568-0860
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Fax |
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Provider Business Mailing Address
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Address Line | 519 E HARRIS ST
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City | SAVANNAH
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State | GA
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Zip | 31401-4621
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Country | US
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Telephone | 912-695-7021
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPC014016
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | PC011832
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License Number State | PA
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Taxonomy #3
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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