MEDICARE: DAVIDA JACKSON

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	363A00000X	Physician Assistant	018541	NY

General Provider Information

NPI Number	:	1285028860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVIDA JACKSON

Provider Business Mailing Address
First Line	:	1029 REMSEN AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11236-3222
Country	:	US
Telephone Number	:	347-683-0470
Fax Number	:

Provider Business Practice Location Address
First Line	:	900 LENOX RD
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11203-2603
Country	:	US
Telephone Number	:	718-342-7733
Fax Number	:

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

Provider Enumeration Date	:	03/23/2015
Last Update Date	:	08/29/2023

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