Provider Demographics
NPI:1437836665
Name:JACKSON, DALLAS TAYLOR
Entity type:Individual
Prefix:
First Name:DALLAS
Middle Name:TAYLOR
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 1:5021 BEVERLY LN
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:DE
Mailing Address - Zip Code:19968-9373
Mailing Address - Country:US
Mailing Address - Phone:302-569-2463
Mailing Address - Fax:
Practice Address - Street 1:18068 COASTAL HWY
Practice Address - Street 2:
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958-4901
Practice Address - Country:US
Practice Address - Phone:302-567-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-29
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEL1-0055490163W00000X
DELG-0012827363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse