Provider Demographics
NPI:1154841120
Name:JACKSON, SERIDA MARIE (LPN)
Entity Type:Individual
Prefix:MS
First Name:SERIDA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 COUNTISBURY AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-1748
Mailing Address - Country:US
Mailing Address - Phone:516-270-0943
Mailing Address - Fax:
Practice Address - Street 1:106 COUNTISBURY AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-1748
Practice Address - Country:US
Practice Address - Phone:516-270-0943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY328081164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY124742419Medicaid