Provider Demographics
NPI:1083923353
Name:JACKSON, KIMBERLY A (PMHNP, FNP)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PMHNP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 CLAYTON BLVD APT 323
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:10505-2058
Mailing Address - Country:US
Mailing Address - Phone:914-343-3149
Mailing Address - Fax:878-213-4061
Practice Address - Street 1:49 CLAYTON BLVD APT 323
Practice Address - Street 2:
Practice Address - City:BALDWIN PLACE
Practice Address - State:NY
Practice Address - Zip Code:10505-2058
Practice Address - Country:US
Practice Address - Phone:914-343-3149
Practice Address - Fax:878-213-4061
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-04
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12.007638363LP0808X
NY336506363LF0000X
NY403954363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03280733Medicaid
NYA9000065369Medicare PIN