Provider Demographics
NPI:1477325645
Name:JACKSON, DENERA RENAE
Entity Type:Individual
Prefix:
First Name:DENERA
Middle Name:RENAE
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 1:3204 SUMMER PL # 2
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-7043
Mailing Address - Country:US
Mailing Address - Phone:252-717-7401
Mailing Address - Fax:
Practice Address - Street 1:3204 SUMMER PL # 2
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7043
Practice Address - Country:US
Practice Address - Phone:252-717-7401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty