Provider Demographics
NPI:1770711459
Name:JACKSON, DANIELLE LEENORA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:DANIELLE
Middle Name:LEENORA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:DANIELLE
Other - Middle Name:LEENORA
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:630 DRAKE AVE
Mailing Address - Street 2:
Mailing Address - City:SAUSALITO
Mailing Address - State:CA
Mailing Address - Zip Code:94965-1107
Mailing Address - Country:US
Mailing Address - Phone:415-339-8813
Mailing Address - Fax:
Practice Address - Street 1:630 DRAKE AVE
Practice Address - Street 2:
Practice Address - City:SAUSALITO
Practice Address - State:CA
Practice Address - Zip Code:94965-1107
Practice Address - Country:US
Practice Address - Phone:415-339-8813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-01
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA030597363A00000X
MDC0003980363A00000X
CAPA21525363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant