Provider Demographics
NPI:1043698384
Name:JACKSON, SEOLAR L (PMNP-BC)
Entity Type:Individual
Prefix:
First Name:SEOLAR
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PMNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 SWEET HOME RD
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14228-2129
Mailing Address - Country:US
Mailing Address - Phone:716-444-8635
Mailing Address - Fax:
Practice Address - Street 1:768 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14209-2006
Practice Address - Country:US
Practice Address - Phone:716-882-3151
Practice Address - Fax:716-886-4002
Is Sole Proprietor?:No
Enumeration Date:2015-05-07
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY621214163W00000X
NY403929363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse