Provider Demographics
NPI:1780825984
Name:JACKSON, DANA R (MD)
Entity Type:Individual
Prefix:DR
First Name:DANA
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 S PACA ST APT 609
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-0426
Mailing Address - Country:US
Mailing Address - Phone:703-568-9597
Mailing Address - Fax:
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:703-568-9597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-18
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDD702932085R0202X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound