Healthcare Provider Details

I. General information

NPI: 1265411474
Provider Name (Legal Business Name): HARRY JACKSON MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 01/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 ALCOTT PL
BRONX NY
10475-4302
US

IV. Provider business mailing address

2600 NETHERLAND AVE
BRONX NY
10463-4801
US

V. Phone/Fax

Practice location:
  • Phone: 718-379-4444
  • Fax:
Mailing address:
  • Phone: 718-379-4444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number511301
License Number StateNY

VIII. Authorized Official

Name: HARRY JACKSON
Title or Position: SOLE PROPRIETER
Credential:
Phone: 718-379-4444