Provider Demographics
NPI:1003098633
Name:JACKSON, DORIAN D'SHAN (MSN, APN-C)
Entity Type:Individual
Prefix:MRS
First Name:DORIAN
Middle Name:D'SHAN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSN, APN-C
Other - Prefix:MRS
Other - First Name:DORIAN
Other - Middle Name:D'SHAN
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSN, APN-C
Mailing Address - Street 1:301 LIPPINCOTT DRIVE SUITE 410
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-0001
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:856-355-0330
Practice Address - Street 1:1010 HADDONFIELD BERLIN RD STE 400
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-3514
Practice Address - Country:US
Practice Address - Phone:856-435-7007
Practice Address - Fax:856-435-4372
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NO12442500163W00000X
NJ26NJ00070500363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0226254Medicaid
NJ125071Medicare Oscar/Certification