Healthcare Provider Details

I. General information

NPI: 1922925361
Provider Name (Legal Business Name): AVENUE TO HOPE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4106 W BEVERLY RD
LAVEEN AZ
85339-2534
US

IV. Provider business mailing address

4106 W BEVERLY RD
LAVEEN AZ
85339-2534
US

V. Phone/Fax

Practice location:
  • Phone: 602-750-0749
  • Fax:
Mailing address:
  • Phone: 602-750-0749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. SHASA LYNN JACKSON
Title or Position: OWNER/MANAGING MEMBER
Credential: LCSW, DBH
Phone: 602-750-0749