MEDICARE: DR. DANETTE M. JACKSON DO

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	207Q00000X	Family Medicine Physician	DO-02419	IA

General Provider Information

NPI Number	:	1083717078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DANETTE M. JACKSON DO

Provider Business Mailing Address
First Line	:	590 MEDICAL CENTER ROAD
Second Line	:
City	:	FT. CAVAZOS
State	:	TX
Zip	:	76544
Country	:	US
Telephone Number	:	254-288-8000
Fax Number	:

Provider Business Practice Location Address
First Line	:	BLDG 2245, 761ST TANK DESTROYER BLVD
Second Line	:	CHARLES THOMAS MOORE CLINIC
City	:	FT CAVAZOS
State	:	TX
Zip	:	76544
Country	:	US
Telephone Number	:	254-285-6232
Fax Number	:

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

Provider Enumeration Date	:	09/06/2006
Last Update Date	:	08/14/2023

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