Provider Demographics
NPI:1790111946
Name:JACKSON, DELILAH YVETTE
Entity Type:Individual
Prefix:
First Name:DELILAH
Middle Name:YVETTE
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 1:2115 S CEDARBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2730
Mailing Address - Country:US
Mailing Address - Phone:417-619-2768
Mailing Address - Fax:
Practice Address - Street 1:2115 S CEDARBROOK AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2730
Practice Address - Country:US
Practice Address - Phone:417-619-2768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-19
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker