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General NPI Number Information
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NPI Number | 1083923353
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Entity Type | Individual
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Provider Name | KIMBERLY A JACKSON PMHNP, FNP
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Gender | Female
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Dates
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Enumeration Date | 10/04/2010
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Last Update Date | 04/11/2025
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Provider Practice Location Address
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Address Line | 49 CLAYTON BLVD APT 323
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City | BALDWIN PLACE
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State | NY
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Zip | 10505-2058
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Country | US
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Telephone | 914-343-3149
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Fax | 878-213-4061
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Provider Business Mailing Address
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Address Line | 418 BROADWAY STE R
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City | ALBANY
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State | NY
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Zip | 12207-2922
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Country | US
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Telephone | 347-696-1375
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Fax | 914-222-8973
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 336506
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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 | 12.007638
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License Number State | CT
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Taxonomy #3
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 403954
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License Number State | NY
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