Provider Demographics
NPI:1003672338
Name:JACKSON, DORA RENEE
Entity Type:Individual
Prefix:
First Name:DORA
Middle Name:RENEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1926 APOLLO CT
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-8541
Mailing Address - Country:US
Mailing Address - Phone:205-260-1701
Mailing Address - Fax:
Practice Address - Street 1:1926 APOLLO CT
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-8541
Practice Address - Country:US
Practice Address - Phone:205-260-1701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician