Provider Demographics
NPI:1184196685
Name:JACKSON, MICHELLE MARIA (RN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 E 89TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-1418
Mailing Address - Country:US
Mailing Address - Phone:718-690-5751
Mailing Address - Fax:
Practice Address - Street 1:220 E 89TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-1418
Practice Address - Country:US
Practice Address - Phone:718-690-5751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY397531715Medicaid