Healthcare Provider Details

I. General information

NPI: 1578197588
Provider Name (Legal Business Name): DR. STARR SHALAE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2020
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2627 HYLAN BLVD
STATEN ISLAND NY
10306-4344
US

IV. Provider business mailing address

1305 WALT WHITMAN RD STE 300
MELVILLE NY
11747-4300
US

V. Phone/Fax

Practice location:
  • Phone: 646-533-0990
  • Fax:
Mailing address:
  • Phone: 516-945-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number345211
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number345211
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number345211
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number663663
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: