Healthcare Provider Details

I. General information

NPI: 1174643209
Provider Name (Legal Business Name): DANETTE JACKSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

281 SAWYER DR
DURANGO CO
81303-3409
US

IV. Provider business mailing address

398 MEADOWBROOK DR
BAYFIELD CO
81122-9778
US

V. Phone/Fax

Practice location:
  • Phone: 970-247-5702
  • Fax: 970-247-9126
Mailing address:
  • Phone: 970-247-4502
  • Fax: 970-247-9126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number102807
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: