Individual
DETRA L JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
—
—
172V00000X
Community Health Worker
Primary
—
—
251S00000X
Community/Behavioral Health Agency
—
—
311ZA0620X
Adult Care Home Facility
—
—
315P00000X
Intellectual Disabilities Intermediate Care Facility
—
—
320800000X
Mental Illness Community Based Residential Treatment Facility
—
—
Other
Enumeration date
04/20/2026
Last updated
04/20/2026
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