MEDICARE: JUDITH A JACKSON

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	163W00000X	Registered Nurse	541413	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1356585343	OTHER	NY	SCHOOL NURSING

General Provider Information

NPI Number	:	1356585343
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUDITH A JACKSON

Provider Business Mailing Address
First Line	:	26 ASH ST
Second Line	:
City	:	VALLEY STREAM
State	:	NY
Zip	:	11580-4812
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1622 E 24TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-2402
Country	:	US
Telephone Number	:	516-285-1892
Fax Number	:

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

Provider Enumeration Date	:	04/22/2009
Last Update Date	:	07/21/2010

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Directions to “ JUDITH A JACKSON ” Practice Location

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