Healthcare Provider Details

I. General information

NPI: 1033475637
Provider Name (Legal Business Name): JUDITH SADIAN SMITH-JACKSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2012
Last Update Date: 04/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

546B BUCHANAN AVE
STATEN ISLAND NY
10314-4159
US

IV. Provider business mailing address

546B BUCHANAN AVE
STATEN ISLAND NY
10314
US

V. Phone/Fax

Practice location:
  • Phone: 718-782-0589
  • Fax: 718-384-7715
Mailing address:
  • Phone: 718-782-0589
  • Fax: 718-384-7715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number517231-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number517231-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number517231-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: