Provider Demographics
NPI:1992874234
Name:JACKSON, DANIEL L (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:115 LOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:NEWTONVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02460-1521
Mailing Address - Country:US
Mailing Address - Phone:617-390-1204
Mailing Address - Fax:617-390-1584
Practice Address - Street 1:49 ROBINWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-2156
Practice Address - Country:US
Practice Address - Phone:617-390-1204
Practice Address - Fax:617-390-1584
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA374042084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAC65798Medicare UPIN
MA821046Medicare ID - Type Unspecified