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General NPI Number Information
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NPI Number | 1558206359
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Entity Type | Individual
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Provider Name | DETRA L JACKSON
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Gender | Female
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Dates
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Enumeration Date | 04/20/2026
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Last Update Date | 04/20/2026
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Provider Practice Location Address
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Address Line | 1910 PACIFIC AVE STE 20001046
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City | DALLAS
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State | TX
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Zip | 75201-4529
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Country | US
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Telephone | 305-988-7335
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Fax |
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Provider Business Mailing Address
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Address Line | 1910 PACIFIC AVE STE 20001046
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City | DALLAS
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State | TX
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Zip | 75201-4529
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Country | US
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Telephone | 305-988-7335
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 172A00000X
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Taxonomy Name | Driver
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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Taxonomy #3
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number |
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Taxonomy #4
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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Taxonomy #5
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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Taxonomy #6
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Taxonomy Code | 172V00000X
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Taxonomy Name | Community Health Worker
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License Number |
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