Provider Demographics
NPI:1194959569
Name:JACKNOW, DALE
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:
Last Name:JACKNOW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S SAN MATEO DR
Mailing Address - Street 2:SUITE 208
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3819
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 S SAN MATEO DR
Practice Address - Street 2:SUITE 208
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3819
Practice Address - Country:US
Practice Address - Phone:650-342-3137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6578982080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics