Provider Demographics
NPI:1093272502
Name:JACKSON, ARIELLE LASHAY
Entity Type:Individual
Prefix:
First Name:ARIELLE
Middle Name:LASHAY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ARIELLE
Other - Middle Name:LASHAY
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 6550
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-6550
Mailing Address - Country:US
Mailing Address - Phone:315-782-7445
Mailing Address - Fax:315-779-1184
Practice Address - Street 1:167 POLK ST STE 300
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2770
Practice Address - Country:US
Practice Address - Phone:315-782-7445
Practice Address - Fax:315-779-1184
Is Sole Proprietor?:No
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3372621Medicaid