Provider Demographics
NPI:1447872411
Name:JACKSON, PAMELA ANGELA
Entity type:Individual
Prefix:MISS
First Name:PAMELA
Middle Name:ANGELA
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 1:4115 WISCONSIN AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20016-2812
Mailing Address - Country:US
Mailing Address - Phone:571-835-3023
Mailing Address - Fax:
Practice Address - Street 1:3720 S STREET N.W LESTINE JACKSON
Practice Address - Street 2:HOUSE
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20007
Practice Address - Country:US
Practice Address - Phone:571-835-3023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health