MEDICARE: JACKSON NGO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program		NY

General Provider Information

NPI Number	:	1043153075
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKSON NGO

Provider Business Mailing Address
First Line	:	7907 QUARRY RD
Second Line	:
City	:	MAUMEE
State	:	OH
Zip	:	43537-9447
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	451 CLARKSON AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11203-2054
Country	:	US
Telephone Number	:	844-692-4692
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2026
Last Update Date	:	04/13/2026

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Directions to “ JACKSON NGO ” Practice Location

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