Provider Demographics
NPI:1518032945
Name:JACKSON, LADONNA
Entity Type:Individual
Prefix:
First Name:LADONNA
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 1:1866 N MARBLE RIDGE PL
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-4574
Mailing Address - Country:US
Mailing Address - Phone:520-722-9296
Mailing Address - Fax:
Practice Address - Street 1:1866 N MARBLE RIDGE PL
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-4574
Practice Address - Country:US
Practice Address - Phone:520-722-9296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4932385H00000X
AZBH-2808320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH4932OtherAZ DEPT OF HEALTH SERVICES
AZ764721Medicaid