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General NPI Number Information
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NPI Number | 1194765834
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Entity Type | Individual
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Provider Name | DAINTY J JACKSON D. O.
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Gender | Female
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Dates
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Enumeration Date | 06/08/2006
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Last Update Date | 02/08/2019
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Provider Practice Location Address
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Address Line | 11315 PEMBROOKE SQ STE 112
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City | WALDORF
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State | MD
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Zip | 20603-4806
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Country | US
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Telephone | 301-885-3350
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Fax | 240-222-3899
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Provider Business Mailing Address
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Address Line | PO BOX 7876
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City | UPPER MARLBORO
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State | MD
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Zip | 20792-7876
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Country | US
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Telephone | 301-254-8177
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Fax | 240-222-3899
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | H0058218
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License Number State | MD
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