Provider Demographics
NPI:1770382392
Name:JACKSON, DESTINY
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 PINE KNOLL LN
Mailing Address - Street 2:
Mailing Address - City:HARVEST
Mailing Address - State:AL
Mailing Address - Zip Code:35749-9358
Mailing Address - Country:US
Mailing Address - Phone:938-653-0312
Mailing Address - Fax:
Practice Address - Street 1:115 PINE KNOLL LN
Practice Address - Street 2:
Practice Address - City:HARVEST
Practice Address - State:AL
Practice Address - Zip Code:35749-9358
Practice Address - Country:US
Practice Address - Phone:938-653-0312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-08
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician