Provider Demographics
NPI:1851581078
Name:JACKSON, DESIRAE (CDA)
Entity Type:Individual
Prefix:
First Name:DESIRAE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 CROY AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-1311
Mailing Address - Country:US
Mailing Address - Phone:716-862-8137
Mailing Address - Fax:
Practice Address - Street 1:VA WNY HEALTHCARE SYSTEM
Practice Address - Street 2:3495 BAILEY AVE
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-1311
Practice Address - Country:US
Practice Address - Phone:716-862-8738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant