Provider Demographics
NPI:1033962733
Name:JACKSON, DARLENE
Entity Type:Individual
Prefix:
First Name:DARLENE
Middle Name:
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 1:4307 E ALTA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-5251
Mailing Address - Country:US
Mailing Address - Phone:602-668-1309
Mailing Address - Fax:
Practice Address - Street 1:4307 E ALTA VISTA RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-5251
Practice Address - Country:US
Practice Address - Phone:602-668-1309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171400000XOther Service ProvidersHealth & Wellness CoachGroup - Single Specialty