Healthcare Provider Details

I. General information

NPI: 1235790783
Provider Name (Legal Business Name): DAPHIME JACKSON CSC-AD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DAPHINE CAMPER-JACKSON CSC-AD

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 08/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8737 BROOKS DR STE 108
EASTON MD
21601-7474
US

IV. Provider business mailing address

PO BOX 123
EASTON MD
21601-8901
US

V. Phone/Fax

Practice location:
  • Phone: 800-867-2395
  • Fax: 410-443-0842
Mailing address:
  • Phone: 800-867-2395
  • Fax: 410-443-0842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: