Healthcare Provider Details

I. General information

NPI: 1588907240
Provider Name (Legal Business Name): JACOB COLE JACKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2013
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 E 68TH ST BOX 124
NEW YORK NY
10065-4870
US

IV. Provider business mailing address

525 E 68TH ST BOX 124
NEW YORK NY
10065-4870
US

V. Phone/Fax

Practice location:
  • Phone: 212-746-2959
  • Fax: 212-746-8563
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MA10388000
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number288525
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: