Healthcare Provider Details

I. General information

NPI: 1154969848
Provider Name (Legal Business Name): DELISE K JACKSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2019
Last Update Date: 12/13/2019
Certification Date: 12/13/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3176 ABBOTT RD STE 500
ORCHARD PARK NY
14127-1069
US

IV. Provider business mailing address

3176 ABBOTT RD STE 500
ORCHARD PARK NY
14127-1069
US

V. Phone/Fax

Practice location:
  • Phone: 716-822-2177
  • Fax: 716-822-8165
Mailing address:
  • Phone: 716-822-2177
  • Fax: 716-822-8165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number649257-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: