Provider Demographics
NPI:1679758478
Name:JACKSON, DIMITRIA ELISE
Entity Type:Individual
Prefix:MS
First Name:DIMITRIA
Middle Name:ELISE
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 1:6955 FOOTHILL BLVD.
Mailing Address - Street 2:SUITE 300
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-2421
Mailing Address - Country:US
Mailing Address - Phone:510-577-1906
Mailing Address - Fax:510-577-5618
Practice Address - Street 1:6955 FOOTHILL BLVD.
Practice Address - Street 2:SUITE 300
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-2421
Practice Address - Country:US
Practice Address - Phone:510-577-1906
Practice Address - Fax:510-577-5618
Is Sole Proprietor?:No
Enumeration Date:2007-12-31
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist