Healthcare Provider Details

I. General information

NPI: 1518032945
Provider Name (Legal Business Name): LADONNA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1866 N MARBLE RIDGE PL
TUCSON AZ
85715-4574
US

IV. Provider business mailing address

1866 N MARBLE RIDGE PL
TUCSON AZ
85715-4574
US

V. Phone/Fax

Practice location:
  • Phone: 520-722-9296
  • Fax:
Mailing address:
  • Phone: 520-722-9296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberBH-2808
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code385H00000X
TaxonomyRespite Care
License NumberBH4932
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: