Healthcare Provider Details

I. General information

NPI: 1770112179
Provider Name (Legal Business Name): MRS. DANIELLE CAITLIN JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2020
Last Update Date: 11/04/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SOUTHFIELD DR STE 1220
PLAINFIELD IN
46168-4499
US

IV. Provider business mailing address

1100 SOUTHFIELD DR STE 1220
PLAINFIELD IN
46168-4499
US

V. Phone/Fax

Practice location:
  • Phone: 317-838-3443
  • Fax: 317-838-3444
Mailing address:
  • Phone: 317-838-3443
  • Fax: 317-838-3444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10003155A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: