Provider Demographics
NPI:1770112179
Name:JACKSON, DANIELLE CAITLIN
Entity type:Individual
Prefix:MRS
First Name:DANIELLE
Middle Name:CAITLIN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 SOUTHFIELD DR
Mailing Address - Street 2:STE 1220
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-4499
Mailing Address - Country:US
Mailing Address - Phone:317-838-3443
Mailing Address - Fax:317-838-3444
Practice Address - Street 1:1100 SOUTHFIELD DR STE 1220
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-4499
Practice Address - Country:US
Practice Address - Phone:317-838-3443
Practice Address - Fax:317-838-3444
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-07
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10003155A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant