Provider Demographics
NPI:1043671530
Name:JACKSON, SANDY A
Entity Type:Individual
Prefix:
First Name:SANDY
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 ROCHAMBEAU AVENUE EXT
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:NY
Mailing Address - Zip Code:14806-9606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14 CENTER ST
Practice Address - Street 2:
Practice Address - City:CUBA
Practice Address - State:NY
Practice Address - Zip Code:14727-1002
Practice Address - Country:US
Practice Address - Phone:585-968-3210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-11
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY340897363LF0000X
NY501034163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse