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General NPI Number Information
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NPI Number | 1154944791
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Entity Type | Individual
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Provider Name | OLIVIA JACKSON
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Gender | Female
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Dates
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Enumeration Date | 05/18/2020
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Last Update Date | 03/23/2023
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Provider Practice Location Address
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Address Line | 570 LEXINGTON AVE FL 9
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City | NEW YORK
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State | NY
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Zip | 10022-6710
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Country | US
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Telephone | 164-696-2727
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Fax |
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Provider Business Mailing Address
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Address Line | 570 LEXINGTON AVE FL 9
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City | NEW YORK
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State | NY
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Zip | 10022-6710
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Country | US
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Telephone | 164-696-2727
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 12941328-1206
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License Number State | UT
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