Healthcare Provider Details

I. General information

NPI: 1205844347
Provider Name (Legal Business Name): CARMEN B. JACKSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 ROUTE 9
WAPPINGERS FALLS NY
12590-4131
US

IV. Provider business mailing address

15 REGENT DR
HOPEWELL JUNCTION NY
12533-5503
US

V. Phone/Fax

Practice location:
  • Phone: 845-297-2511
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number332370
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: