Provider Demographics
NPI:1285990622
Name:JACKSON, DESHAUN ANTONIO (DPT)
Entity type:Individual
Prefix:MR
First Name:DESHAUN
Middle Name:ANTONIO
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 WESTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-5055
Mailing Address - Country:US
Mailing Address - Phone:601-807-2619
Mailing Address - Fax:
Practice Address - Street 1:1406 WESTWOOD RD
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-5055
Practice Address - Country:US
Practice Address - Phone:601-807-2619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT 4069174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist