Provider Demographics
NPI:1417333543
Name:JACKSON, DANIELLE R (CRNA)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:R
Other - Last Name:DAVIDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2923 MISSOURI AVE
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-2758
Mailing Address - Country:US
Mailing Address - Phone:417-483-8527
Mailing Address - Fax:
Practice Address - Street 1:444 FOUR STATES DR
Practice Address - Street 2:SUITE 2
Practice Address - City:GALENA
Practice Address - State:KS
Practice Address - Zip Code:66739-4324
Practice Address - Country:US
Practice Address - Phone:620-783-4441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-30
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015025646367500000X
KS43557355122367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered