MEDICARE: MS. SERIDA MARIE JACKSON LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	328081	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154841120
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SERIDA MARIE JACKSON LPN

Provider Business Mailing Address
First Line	:	106 COUNTISBURY AVE
Second Line	:
City	:	VALLEY STREAM
State	:	NY
Zip	:	11580-1748
Country	:	US
Telephone Number	:	516-270-0943
Fax Number	:

Provider Business Practice Location Address
First Line	:	106 COUNTISBURY AVE
Second Line	:
City	:	VALLEY STREAM
State	:	NY
Zip	:	11580-1748
Country	:	US
Telephone Number	:	516-270-0943
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2017
Last Update Date	:	07/21/2022

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