Healthcare Provider Details

I. General information

NPI: 1306813415
Provider Name (Legal Business Name): DR. EMILY JACKNESS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 01/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 BAINBRIDGE AVE CHILDREN'S HOSPITAL AT MONTEFIORE - PEDIATRIC CARDIOLOG
BRONX NY
10467
US

IV. Provider business mailing address

161 CLINTON ST
BROOKLYN NY
11201-4601
US

V. Phone/Fax

Practice location:
  • Phone: 718-741-2343
  • Fax:
Mailing address:
  • Phone: 718-624-8208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number162865
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: