Provider Demographics
NPI:1245381318
Name:JACKSON, ASHLEY DESHAWN
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:DESHAWN
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 1:1708 BANYAN CT
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-1907
Mailing Address - Country:US
Mailing Address - Phone:209-531-2088
Mailing Address - Fax:209-538-7340
Practice Address - Street 1:1708 BANYAN CT
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-1907
Practice Address - Country:US
Practice Address - Phone:209-531-2088
Practice Address - Fax:209-538-7340
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA138133106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist