Provider Demographics
NPI:1588722466
Name:JACKSON, DONALD A (PHD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 54
Mailing Address - Street 2:
Mailing Address - City:VERDI
Mailing Address - State:NV
Mailing Address - Zip Code:89439-0054
Mailing Address - Country:US
Mailing Address - Phone:775-848-5578
Mailing Address - Fax:775-784-4997
Practice Address - Street 1:NCED MS 285
Practice Address - Street 2:UNIVERSITY OF NEVADA, RENO
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89557-1285
Practice Address - Country:US
Practice Address - Phone:775-682-9049
Practice Address - Fax:775-784-4997
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPY119103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2616059Medicaid