Healthcare Provider Details

I. General information

NPI: 1205532801
Provider Name (Legal Business Name): NIXON JEAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 04/19/2023
Certification Date: 04/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2873 W 17TH ST FL 2
BROOKLYN NY
11224-2611
US

IV. Provider business mailing address

2873 W 17TH ST FL 2
BROOKLYN NY
11224-2611
US

V. Phone/Fax

Practice location:
  • Phone: 718-265-0900
  • Fax: 718-265-6319
Mailing address:
  • Phone: 718-265-0900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberF404753
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number649309
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF404753
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: