Provider Demographics
NPI:1619477973
Name:JACKSON, DASARAY
Entity Type:Individual
Prefix:MISS
First Name:DASARAY
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 1:3201 W DESERT COVE AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-4211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20860 N TATUM BLVD STE 300
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-4283
Practice Address - Country:US
Practice Address - Phone:866-342-8847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-13
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRBT-16-13608106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician