Provider Demographics
NPI:1679213110
Name:JACKSON, DONYA
Entity Type:Individual
Prefix:
First Name:DONYA
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 1:312 CRESTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PLAIN DEALING
Mailing Address - State:LA
Mailing Address - Zip Code:71064-3559
Mailing Address - Country:US
Mailing Address - Phone:318-578-7452
Mailing Address - Fax:
Practice Address - Street 1:246 BLANKENSHIP RD
Practice Address - Street 2:
Practice Address - City:PLAIN DEALING
Practice Address - State:LA
Practice Address - Zip Code:71064-4619
Practice Address - Country:US
Practice Address - Phone:318-326-4623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-31
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant