MEDICARE: MRS. DANA JACKIW NP

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	363LF0000X	Family Nurse Practitioner	F333834	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	112368CW	OTHER	NY	PREFERRED CARE

General Provider Information

NPI Number	:	1255429825
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DANA JACKIW NP

Provider Business Mailing Address
First Line	:	973 EAST AVE
Second Line	:	SUITE 100
City	:	ROCHESTER
State	:	NY
Zip	:	14607-2216
Country	:	US
Telephone Number	:	585-244-1000
Fax Number	:

Provider Business Practice Location Address
First Line	:	973 EAST AVE
Second Line	:	SUITE 100
City	:	ROCHESTER
State	:	NY
Zip	:	14607-2216
Country	:	US
Telephone Number	:	585-244-1000
Fax Number	:

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

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	07/08/2007

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