Provider Demographics
NPI:1205844347
Name:JACKSON, CARMEN B (FNP)
Entity Type:Individual
Prefix:MS
First Name:CARMEN
Middle Name:B
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 REGENT DR
Mailing Address - Street 2:
Mailing Address - City:HOPEWELL JUNCTION
Mailing Address - State:NY
Mailing Address - Zip Code:12533-5503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1530 ROUTE 9
Practice Address - Street 2:
Practice Address - City:WAPPINGERS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12590-4131
Practice Address - Country:US
Practice Address - Phone:845-297-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY332370163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator