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General NPI Number Information
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NPI Number | 1780968628
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Entity Type | Individual
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Provider Name | DERISHA JACKSON
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Gender | Female
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Dates
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Enumeration Date | 10/10/2011
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Last Update Date | 10/10/2011
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Provider Practice Location Address
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Address Line | 351 N AIR DEPOT BLVD SUITE S
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City | MIDWEST CITY
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State | OK
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Zip | 73110-1700
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Country | US
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Telephone | 405-610-6540
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Fax |
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Provider Business Mailing Address
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Address Line | 13525 N HOLLOW ROCK RD. APT D
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City | OKLAHOMA CITY
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State | OK
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Zip | 73120
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Country | US
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Telephone | 209-242-4270
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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 | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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