Provider Demographics
NPI:1407330129
Name:JACKSON, DONNA HIBBERT
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:HIBBERT
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 1:1401 E WILLIAMS FIELD RD STE 19
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-1646
Mailing Address - Country:US
Mailing Address - Phone:480-477-1506
Mailing Address - Fax:
Practice Address - Street 1:1401 E WILLIAMS FIELD RD STE 19
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-1646
Practice Address - Country:US
Practice Address - Phone:480-477-1506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1112171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist