Provider Demographics
NPI:1881484913
Name:JACKSON, DESTANEE MARIE
Entity type:Individual
Prefix:
First Name:DESTANEE
Middle Name:MARIE
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 1:140 YALE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01109-3435
Mailing Address - Country:US
Mailing Address - Phone:413-777-2210
Mailing Address - Fax:413-777-2210
Practice Address - Street 1:136 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105-2324
Practice Address - Country:US
Practice Address - Phone:413-331-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician