Provider Demographics
NPI:1073288122
Name:JACKSON, POPPY CHRISTINA (DNP, AGPCNP-BC)
Entity Type:Individual
Prefix:
First Name:POPPY
Middle Name:CHRISTINA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DNP, AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 E 102ND ST FL 5
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6030
Mailing Address - Country:US
Mailing Address - Phone:212-241-5656
Mailing Address - Fax:646-537-9540
Practice Address - Street 1:10 E 102ND ST FL 5
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6030
Practice Address - Country:US
Practice Address - Phone:212-241-5656
Practice Address - Fax:646-537-9540
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310258363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health