Provider Demographics
NPI:1356970263
Name:JACKSON, AYANA (PLPC)
Entity type:Individual
Prefix:MRS
First Name:AYANA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3730 HUMPHREY ST APT A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-4824
Mailing Address - Country:US
Mailing Address - Phone:314-922-5563
Mailing Address - Fax:
Practice Address - Street 1:11042 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-1244
Practice Address - Country:US
Practice Address - Phone:314-527-0554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional