MEDICARE: DANIELLE LAWANNA JACKSON RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	9380491	FL

General Provider Information

NPI Number	:	1033585831
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIELLE LAWANNA JACKSON RN

Provider Business Mailing Address
First Line	:	213 BIRKDALE DR
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32124-2053
Country	:	US
Telephone Number	:	386-334-1476
Fax Number	:

Provider Business Practice Location Address
First Line	:	213 BIRKDALE DR
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32124-2053
Country	:	US
Telephone Number	:	386-334-1476
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/15/2015
Last Update Date	:	04/04/2025

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