MEDICARE: KEWUAN DESHAUN JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	385HR2055X	Child Mental Illness Respite Care	1490923	AZ

General Provider Information

NPI Number	:	1639300874
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEWUAN DESHAUN JACKSON

Provider Business Mailing Address
First Line	:	4880 N SABINO CANYON RD
Second Line	:	APT 14160
City	:	TUCSON
State	:	AZ
Zip	:	85750-7006
Country	:	US
Telephone Number	:	520-818-4318
Fax Number	:

Provider Business Practice Location Address
First Line	:	4880 N SABINO CANYON RD
Second Line	:	APT 14160
City	:	TUCSON
State	:	AZ
Zip	:	85750-7006
Country	:	US
Telephone Number	:	520-818-4318
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2009
Last Update Date	:	08/05/2009

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