Provider Demographics
NPI:1679620652
Name:JACKSON, ANITA P (PHD)
Entity type:Individual
Prefix:DR
First Name:ANITA
Middle Name:P
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:ANITA
Other - Middle Name:P
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:573 BROOKOVER AVE
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-2101
Mailing Address - Country:US
Mailing Address - Phone:740-450-7620
Mailing Address - Fax:740-450-7618
Practice Address - Street 1:573 BROOKOVER AVE
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-2101
Practice Address - Country:US
Practice Address - Phone:740-450-7620
Practice Address - Fax:740-450-7618
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE1514101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH311814468031OtherCARESOURCE
OH000000517637OtherANTHEM