Provider Demographics
NPI:1104908417
Name:JACKSON, JESSIE R
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RAYMOND
Other - Middle Name:L
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9855 E IRVINGTON RD
Mailing Address - Street 2:UNIT #82
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85730-5220
Mailing Address - Country:US
Mailing Address - Phone:520-733-1165
Mailing Address - Fax:520-733-1165
Practice Address - Street 1:9855 E IRVINGTON RD
Practice Address - Street 2:UNIT #82
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85730-5220
Practice Address - Country:US
Practice Address - Phone:520-733-1165
Practice Address - Fax:520-733-1165
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3923385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3923Medicare UPIN