Provider Demographics
NPI:1841818531
Name:JACKSON, DANIELLE BEVERLY
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:BEVERLY
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 1:337 NE 51ST RD
Mailing Address - Street 2:
Mailing Address - City:WARRENSBURG
Mailing Address - State:MO
Mailing Address - Zip Code:64093-7490
Mailing Address - Country:US
Mailing Address - Phone:913-369-5897
Mailing Address - Fax:
Practice Address - Street 1:337 NE 51ST RD
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093-7490
Practice Address - Country:US
Practice Address - Phone:913-369-5897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022004186235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist