Provider Demographics
NPI:1780968628
Name:JACKSON, DERISHA
Entity type:Individual
Prefix:
First Name:DERISHA
Middle Name:
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 1:13525 N HOLLOW ROCK RD.
Mailing Address - Street 2:APT D
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120
Mailing Address - Country:US
Mailing Address - Phone:209-242-4270
Mailing Address - Fax:
Practice Address - Street 1:351 N AIR DEPOT BLVD
Practice Address - Street 2:SUITE S
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-1700
Practice Address - Country:US
Practice Address - Phone:405-610-6540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor