Provider Demographics
NPI:1689924433
Name:JACKSON, DONNITA KAYE
Entity Type:Individual
Prefix:
First Name:DONNITA
Middle Name:KAYE
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 1:1210 SOUTH TRACE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745
Mailing Address - Country:US
Mailing Address - Phone:512-888-5985
Mailing Address - Fax:
Practice Address - Street 1:1210 SOUTH TRACE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745
Practice Address - Country:US
Practice Address - Phone:512-888-5985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities