Provider Demographics
NPI:1639360647
Name:JACKSON, DARLENE VICTORIA (OTR/L)
Entity Type:Individual
Prefix:MISS
First Name:DARLENE
Middle Name:VICTORIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3233 W PEORIA AVE
Mailing Address - Street 2:STE 224
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-4614
Mailing Address - Country:US
Mailing Address - Phone:602-866-2231
Mailing Address - Fax:
Practice Address - Street 1:3233 W PEORIA AVE
Practice Address - Street 2:STE 224
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-4614
Practice Address - Country:US
Practice Address - Phone:602-866-2231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3656174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist