Active NPI
Kewuan Deshaun Jackson
- Child Mental Illness Respite Care
- Tucson, AZ
National Provider Identifier
1639300874
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Child Mental Illness Respite Care
- License
- 1490923
- Practice address
- 4880 N Sabino Canyon Rd
Apt 14160
Tucson, AZ 85750-7006 - Phone
- (520) 818-4318
- NPI assigned
- Aug 5, 2009
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Child Mental Illness Respite Care | 385HR2055X | 1490923 | AZ | Primary |
Addresses
Primary practice location
4880 N Sabino Canyon Rd
Apt 14160
Tucson, AZ 85750-7006
Mailing address
4880 N Sabino Canyon Rd
Apt 14160
Tucson, AZ 85750-7006
Phone (520) 818-4318
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1490923 | AZ | MD | Child Mental Illness Respite Care |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1249430400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1249430400000",
"number": "1639300874",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4880 N SABINO CANYON RD",
"address_2": "APT 14160",
"city": "TUCSON",
"state": "AZ",
"postal_code": "857507006",
"telephone_number": "520-818-4318"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4880 N SABINO CANYON RD",
"address_2": "APT 14160",
"city": "TUCSON",
"state": "AZ",
"postal_code": "857507006",
"telephone_number": "520-818-4318"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "KEWUAN",
"middle_name": "DESHAUN",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2009-08-05",
"last_updated": "2009-08-05",
"status": "A"
},
"taxonomies": [
{
"code": "385HR2055X",
"taxonomy_group": "",
"desc": "Respite Care, Respite Care, Mental Illness, Child",
"state": "AZ",
"license": "1490923",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Tucson, AZ
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 5, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.