Healthcare Provider Details

I. General information

NPI: 1437836665
Provider Name (Legal Business Name): DALLAS TAYLOR JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2023
Last Update Date: 12/21/2025
Certification Date: 12/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19277 PLANTATION RD
REHOBOTH BEACH DE
19971-4411
US

IV. Provider business mailing address

19277 PLANTATION RD
REHOBOTH BEACH DE
19971-4411
US

V. Phone/Fax

Practice location:
  • Phone: 302-567-1500
  • Fax:
Mailing address:
  • Phone: 302-567-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberLG-0012827
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberL1-0055490
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: