Provider Demographics
NPI:1275364465
Name:JACKSON, AMANDA SUE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:SUE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:SUE
Other - Last Name:LOUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:84 JACK SULLINS RD
Mailing Address - Street 2:
Mailing Address - City:SPRUCE PINE
Mailing Address - State:NC
Mailing Address - Zip Code:28777-8450
Mailing Address - Country:US
Mailing Address - Phone:828-467-2206
Mailing Address - Fax:
Practice Address - Street 1:200 SWANNANOA RIVER RD
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28805-2216
Practice Address - Country:US
Practice Address - Phone:857-829-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-09
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician