Healthcare Provider Details

I. General information

NPI: 1508623240
Provider Name (Legal Business Name): DESHAE RENEE JACKSON CD(DONA)
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/29/2024
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2137 RAVENWOOD AVE
DAYTON OH
45406-2907
US

IV. Provider business mailing address

2137 RAVENWOOD AVE
DAYTON OH
45406-2907
US

V. Phone/Fax

Practice location:
  • Phone: 714-514-3366
  • Fax:
Mailing address:
  • Phone: 714-541-3366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: