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General NPI Number Information
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NPI Number | 1043698384
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Entity Type | Individual
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Provider Name | SEOLAR L JACKSON PMNP-BC
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Gender | Female
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Dates
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Enumeration Date | 05/07/2015
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Last Update Date | 11/09/2022
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Provider Practice Location Address
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Address Line | 768 DELAWARE AVE
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City | BUFFALO
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State | NY
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Zip | 14209-2006
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Country | US
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Telephone | 716-882-3151
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Fax | 716-886-4002
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Provider Business Mailing Address
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Address Line | 2605 SWEET HOME RD
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City | AMHERST
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State | NY
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Zip | 14228-2129
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Country | US
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Telephone | 716-444-8635
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 621214
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 403929
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License Number State | NY
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