Provider Demographics
NPI:1750773388
Name:JACKSON, DANIEL
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
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 1:81557 DR CARREON BLVD STE C9
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-5562
Mailing Address - Country:US
Mailing Address - Phone:760-391-6999
Mailing Address - Fax:760-347-5614
Practice Address - Street 1:81557 DR CARREON BLVD STE C9
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-5562
Practice Address - Country:US
Practice Address - Phone:760-391-6999
Practice Address - Fax:760-347-5614
Is Sole Proprietor?:No
Enumeration Date:2015-02-18
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator