Provider Demographics
NPI:1013368026
Name:JACKSON, DEAUNDRA BRISHA (MA)
Entity Type:Individual
Prefix:
First Name:DEAUNDRA
Middle Name:BRISHA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5812
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32447-5812
Mailing Address - Country:US
Mailing Address - Phone:850-427-3079
Mailing Address - Fax:
Practice Address - Street 1:7940 FRONT BEACH RD # 2148
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32407-4817
Practice Address - Country:US
Practice Address - Phone:850-427-3079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-30
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11938110103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst