Provider Demographics
NPI:1487023867
Name:JACKSON, DANIELLE MICHELLE (CERTIFIED NURSING AS)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MICHELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CERTIFIED NURSING AS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 600
Mailing Address - Street 2:167 NORTH MAIN STREET
Mailing Address - City:TUBA CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86045
Mailing Address - Country:US
Mailing Address - Phone:928-283-2781
Mailing Address - Fax:928-283-2677
Practice Address - Street 1:167 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:TUBA CITY
Practice Address - State:AZ
Practice Address - Zip Code:86045
Practice Address - Country:US
Practice Address - Phone:928-283-2781
Practice Address - Fax:928-283-2677
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCNA1000046611376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide