Individual
ANTOINETTE ROSA JACKSON (AZIZ)
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LPC
Contact information
Practice address
6122 RIDGE AVE, PHILADELPHIA, PA 19128-1603
(215) 487-1330
Mailing address
6014 CATHARINE ST # B, PHILADELPHIA, PA 19143-2306
(215) 432-8608
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
Primary
PC009302
PA
Other
Enumeration date
07/24/2019
Last updated
07/24/2019
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