Provider Demographics
NPI:1942031653
Name:JACKSON, MIA A
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 PENNSYLVANIA AVE SE UNIT 15707
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-7529
Mailing Address - Country:US
Mailing Address - Phone:443-690-5857
Mailing Address - Fax:
Practice Address - Street 1:600 PENNSYLVANIA AVE SE UNIT 15707
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20003-7529
Practice Address - Country:US
Practice Address - Phone:443-690-5857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA103K00000X103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst