Basic Information
Provider Information | |||||||||
NPI: | 1003098633 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACKSON | ||||||||
FirstName: | DORIAN | ||||||||
MiddleName: | D'SHAN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSN, APN-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JACKSON | ||||||||
OtherFirstName: | DORIAN | ||||||||
OtherMiddleName: | D'SHAN | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MSN, APN-C | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 22581 | ||||||||
Address2: |   | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100872581 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8566696050 | ||||||||
FaxNumber: | 8565413340 | ||||||||
Practice Location | |||||||||
Address1: | 1010 HADDONFIELD BERLIN RD STE 400 | ||||||||
Address2: |   | ||||||||
City: | VOORHEES | ||||||||
State: | NJ | ||||||||
PostalCode: | 080433514 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8564357007 | ||||||||
FaxNumber: | 8564354372 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/05/2007 | ||||||||
LastUpdateDate: | 08/18/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/18/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 26NO12442500 | NJ | N |   | Nursing Service Providers | Registered Nurse |   | 363LX0001X | 26NJ00070500 | NJ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology |
ID Information
ID | Type | State | Issuer | Description | 0226254 | 05 | NJ |   | MEDICAID |