Provider Demographics
NPI:1114314812
Name:JACKSON, DARTANIA S
Entity Type:Individual
Prefix:
First Name:DARTANIA
Middle Name:S
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 FAIRWAY DR
Mailing Address - Street 2:STE. 102
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-1814
Mailing Address - Country:US
Mailing Address - Phone:888-880-9270
Mailing Address - Fax:
Practice Address - Street 1:8501 WADE BLVD STE 1250
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-5894
Practice Address - Country:US
Practice Address - Phone:972-312-8733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-20
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist