Provider Demographics
NPI:1871110361
Name:JACKSON, DANA SIERRA (PA)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:SIERRA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:
Other - Last Name:RANDALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2865 DAGGETT AVE
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-1106
Mailing Address - Country:US
Mailing Address - Phone:541-274-8400
Mailing Address - Fax:541-274-8405
Practice Address - Street 1:2821 DAGGETT AVE STE 200
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1130
Practice Address - Country:US
Practice Address - Phone:541-274-8400
Practice Address - Fax:541-274-8405
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA201846363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant