Provider Demographics
NPI:1437836665
Name:JACKSON, DALLAS TAYLOR
Entity Type:Individual
Prefix:
First Name:DALLAS
Middle Name:TAYLOR
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 1:417 SAMUEL ST
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76207-1778
Mailing Address - Country:US
Mailing Address - Phone:302-569-2463
Mailing Address - Fax:
Practice Address - Street 1:3303 COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210-6812
Practice Address - Country:US
Practice Address - Phone:940-484-1887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-29
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1096228163W00000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse