MEDICARE: MS. ROSEMARY MAXINE JACKSON M.D.

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	208000000X	Pediatrics Physician	169649	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	:	1801878921
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ROSEMARY MAXINE JACKSON M.D.

Provider Business Mailing Address
First Line	:	20514 115TH AVE
Second Line	:
City	:	SAINT ALBANS
State	:	NY
Zip	:	11412-2904
Country	:	US
Telephone Number	:	718-363-6646
Fax Number	:	718-363-6746

Provider Business Practice Location Address
First Line	:	900 LENOX RD
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11203-2603
Country	:	US
Telephone Number	:	718-342-3579
Fax Number	:	718-342-3281

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

Provider Enumeration Date	:	11/15/2005
Last Update Date	:	05/27/2021

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