Provider Demographics
NPI:1639300874
Name:JACKSON, KEWUAN DESHAUN
Entity Type:Individual
Prefix:
First Name:KEWUAN
Middle Name:DESHAUN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4880 N SABINO CANYON RD
Mailing Address - Street 2:APT 14160
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85750-7006
Mailing Address - Country:US
Mailing Address - Phone:520-818-4318
Mailing Address - Fax:
Practice Address - Street 1:4880 N SABINO CANYON RD
Practice Address - Street 2:APT 14160
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85750-7006
Practice Address - Country:US
Practice Address - Phone:520-818-4318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-05
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1490923385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child