Provider Demographics
NPI:1366047052
Name:JACKSON, AMANDA R (BCAT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:BCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 MID VALLEY CTR # 186
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:CA
Mailing Address - Zip Code:93923-8516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:280 PINEHURST AVE STE 7
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-7089
Practice Address - Country:US
Practice Address - Phone:800-991-6070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00012644106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician