Provider Demographics
NPI:1750550919
Name:JACKSON, DANIELLE MARGARET COLETTE (MD)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MARGARET COLETTE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 BEAM AVE
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1126
Mailing Address - Country:US
Mailing Address - Phone:651-232-7000
Mailing Address - Fax:
Practice Address - Street 1:1575 BEAM AVE
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1126
Practice Address - Country:US
Practice Address - Phone:651-232-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-21
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN19594207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN19594OtherRESIDENCY PERMIT NUMBER