Provider Demographics
NPI:1467661306
Name:JACKSON, DOROTHY LYN (CNA)
Entity Type:Individual
Prefix:DR
First Name:DOROTHY
Middle Name:LYN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1646 ELMIRA ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80010-2122
Mailing Address - Country:US
Mailing Address - Phone:303-617-2656
Mailing Address - Fax:303-617-2832
Practice Address - Street 1:1646 ELMIRA ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80010-2122
Practice Address - Country:US
Practice Address - Phone:303-617-2656
Practice Address - Fax:303-617-2832
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO163103390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program