Provider Demographics
NPI:1336804533
Name:JACKSON, DONTEE LAMONE
Entity Type:Individual
Prefix:
First Name:DONTEE
Middle Name:LAMONE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1959 ILEX AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-3950
Mailing Address - Country:US
Mailing Address - Phone:619-852-5915
Mailing Address - Fax:
Practice Address - Street 1:4460 DELTA ST APT 8
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113-4166
Practice Address - Country:US
Practice Address - Phone:619-432-1070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider