=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841341054
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARGARET ALENE JACKSON M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2698 FREDERICK DOUGLASS BLVD
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10030-1219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-939-8966
-----------------------------------------------------
Fax | 212-939-8973
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 MICHELLE ST
-----------------------------------------------------
City | MONROE TOWNSHIP
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08831-8620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-723-1560
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 156733-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------