Provider Demographics
NPI:1033475637
Name:SMITH-JACKSON, JUDITH SADIAN (RN)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:SADIAN
Last Name:SMITH-JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:546B BUCHANAN AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314
Mailing Address - Country:US
Mailing Address - Phone:718-782-0589
Mailing Address - Fax:718-384-7715
Practice Address - Street 1:546B BUCHANAN AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-4159
Practice Address - Country:US
Practice Address - Phone:718-782-0589
Practice Address - Fax:718-384-7715
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-09
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY517231-1163W00000X, 163WC1500X, 163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No163W00000XNursing Service ProvidersRegistered Nurse
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health