Provider Demographics
NPI:1740737493
Name:JACKSON, DESHA DIONE (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:DESHA
Middle Name:DIONE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:DESMA
Other - Middle Name:DIONE
Other - Last Name:GENTRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5730 NORTH FIRST ST SUITE 105-200
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-3307
Mailing Address - Country:US
Mailing Address - Phone:559-212-4970
Mailing Address - Fax:
Practice Address - Street 1:2501 W SHAW AVE STE 119
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3307
Practice Address - Country:US
Practice Address - Phone:559-573-7991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-09
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF78130106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist