Healthcare Provider Details

I. General information

NPI: 1114328366
Provider Name (Legal Business Name): DANA MARIE JACKSON DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2014
Last Update Date: 08/31/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S STATE HIGHWAY 125
STRAFFORD MO
65757-8997
US

IV. Provider business mailing address

6950 NE CAMPUS WAY
HILLSBORO OR
97124-5611
US

V. Phone/Fax

Practice location:
  • Phone: 417-631-4490
  • Fax:
Mailing address:
  • Phone: 618-560-8849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2023031197
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2023031197
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: