Provider Demographics
NPI:1194765834
Name:JACKSON, DAINTY J (D O)
Entity type:Individual
Prefix:
First Name:DAINTY
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:F
Credentials:D O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7876
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20792-7876
Mailing Address - Country:US
Mailing Address - Phone:301-254-8177
Mailing Address - Fax:240-222-3899
Practice Address - Street 1:11315 PEMBROOKE SQ STE 112
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4806
Practice Address - Country:US
Practice Address - Phone:301-885-3350
Practice Address - Fax:240-222-3899
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0058218207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD401725102Medicaid
MD069SMedicare ID - Type Unspecified
MD401725102Medicaid