Provider Demographics
NPI:1215373980
Name:JACKSON, MINYELLE (LPN)
Entity Type:Individual
Prefix:
First Name:MINYELLE
Middle Name:
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 1:801 CROOKED HILL RD # 325
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-1045
Mailing Address - Country:US
Mailing Address - Phone:631-671-5798
Mailing Address - Fax:
Practice Address - Street 1:801 CROOKED HILL RD # 325
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-1045
Practice Address - Country:US
Practice Address - Phone:631-671-5798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY287782164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse