Provider Demographics
NPI:1083717078
Name:JACKSON, DANETTE M (DO)
Entity Type:Individual
Prefix:DR
First Name:DANETTE
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 MEDICAL CENTER ROAD
Mailing Address - Street 2:
Mailing Address - City:FT. CAVAZOS
Mailing Address - State:TX
Mailing Address - Zip Code:76544
Mailing Address - Country:US
Mailing Address - Phone:254-288-8000
Mailing Address - Fax:
Practice Address - Street 1:BLDG 2245, 761ST TANK DESTROYER BLVD
Practice Address - Street 2:CHARLES THOMAS MOORE CLINIC
Practice Address - City:FT CAVAZOS
Practice Address - State:TX
Practice Address - Zip Code:76544
Practice Address - Country:US
Practice Address - Phone:254-285-6232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADO-02419207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA49326Medicare ID - Type Unspecified
IAE97781Medicare UPIN