Healthcare Provider Details

I. General information

NPI: 1033389648
Provider Name (Legal Business Name): LYMARILYS JACKSON PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2008
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date: 07/10/2026
Reactivation Date: 07/30/2026

III. Provider practice location address

315 MADISON AVE RM 2000
NEW YORK NY
10017-5416
US

IV. Provider business mailing address

35 BOCA PL
EAST AMHERST NY
14051-1080
US

V. Phone/Fax

Practice location:
  • Phone: 646-661-5225
  • Fax:
Mailing address:
  • Phone: 716-896-6175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number408635
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: