Healthcare Provider Details

I. General information

NPI: 1841482031
Provider Name (Legal Business Name): JENNIFER ANN JACKSON RPAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 04/29/2022
Certification Date: 04/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 LAUREL AVE STE 102
CORNWALL NY
12518-1403
US

IV. Provider business mailing address

19 LAUREL AVE STE 102
CORNWALL NY
12518-1403
US

V. Phone/Fax

Practice location:
  • Phone: 845-822-8100
  • Fax: 845-822-8110
Mailing address:
  • Phone: 845-822-8100
  • Fax: 845-822-8110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number006236
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: