Provider Demographics
NPI:1689060063
Name:JACKSON, DANA LENORE (DO, MS)
Entity Type:Individual
Prefix:DR
First Name:DANA
Middle Name:LENORE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DO, MS
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:LENORE
Other - Last Name:MCDADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO, MS
Mailing Address - Street 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4541
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:525 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-4007
Practice Address - Country:US
Practice Address - Phone:619-515-2498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-13
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A14119208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics