Provider Demographics
NPI:1114514163
Name:JACKOWSKI, ALEXA (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEXA
Middle Name:
Last Name:JACKOWSKI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 CROSS BAY BLVD
Mailing Address - Street 2:
Mailing Address - City:BROAD CHANNEL
Mailing Address - State:NY
Mailing Address - Zip Code:11693-1220
Mailing Address - Country:US
Mailing Address - Phone:718-216-7374
Mailing Address - Fax:
Practice Address - Street 1:23-89 BELL BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11360
Practice Address - Country:US
Practice Address - Phone:718-631-0072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-23
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026140363A00000X, 207R00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine