Individual
DERISHA JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
351 N AIR DEPOT BLVD, SUITE S, MIDWEST CITY, OK 73110-1700
(405) 610-6540
Mailing address
13525 N HOLLOW ROCK RD., APT D, OKLAHOMA CITY, OK 73120
(209) 242-4270
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
—
—
Other
Enumeration date
10/10/2011
Last updated
10/10/2011
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