Healthcare Provider Details

I. General information

NPI: 1174436547
Provider Name (Legal Business Name): DESIRAE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6856 W MARYLAND AVE UNIT 5111
GLENDALE AZ
85303-0043
US

IV. Provider business mailing address

6856 W MARYLAND AVE UNIT 5111
GLENDALE AZ
85303-0043
US

V. Phone/Fax

Practice location:
  • Phone: 480-266-0314
  • Fax:
Mailing address:
  • Phone: 480-266-0314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: