Healthcare Provider Details

I. General information

NPI: 1609851443
Provider Name (Legal Business Name): MARY J JACKSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 06/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 W SENECA ST
MANLIUS NY
13104-2318
US

IV. Provider business mailing address

1001 W FAYETTE ST STE 400
SYRACUSE NY
13204-2859
US

V. Phone/Fax

Practice location:
  • Phone: 315-682-5080
  • Fax: 315-682-8847
Mailing address:
  • Phone: 315-472-1488
  • Fax: 315-472-8060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number154924
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: