MEDICARE: ANITA ANN JACKSON REGISTERED NURSE

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	163W00000X	Registered Nurse	359701-1	NY

General Provider Information

NPI Number	:	1699273789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANITA ANN JACKSON REGISTERED NURSE

Provider Business Mailing Address
First Line	:	2853 WEBB AVE BRONX NY 10468
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10468-2154
Country	:	US
Telephone Number	:	718-796-3503
Fax Number	:

Provider Business Practice Location Address
First Line	:	2853 WEBB AVE BRONX NY 10468
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10468-2154
Country	:	US
Telephone Number	:	718-796-3503
Fax Number	:

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

Provider Enumeration Date	:	01/24/2018
Last Update Date	:	01/24/2018

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