Healthcare Provider Details

I. General information

NPI: 1700525854
Provider Name (Legal Business Name): JACKY SALOMON PETION DR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2022
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BROOKDALE PLZ, BROOKLYN
BROOKLYN NY
11212-3139
US

IV. Provider business mailing address

60 FENWOOD RD FL 9
BOSTON MA
02115-6128
US

V. Phone/Fax

Practice location:
  • Phone: 718-613-4334
  • Fax:
Mailing address:
  • Phone: 781-416-8414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number1026480
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: