Provider Demographics
NPI:1982414660
Name:JACKSON, AYANNA (MSW, LMSW)
Entity type:Individual
Prefix:
First Name:AYANNA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 MCILVAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19013-6234
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10190 BANNOCK ST STE 120
Practice Address - Street 2:
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80260-6052
Practice Address - Country:US
Practice Address - Phone:719-482-0418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-13
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0009925327104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker