Provider Demographics
NPI:1235381732
Name:JERREYLL T JACKSON M.D. P.C
Entity Type:Organization
Organization Name:JERREYLL T JACKSON M.D. P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JERREYLL
Authorized Official - Middle Name:T
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-889-1171
Mailing Address - Street 1:20 E 46TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017-2417
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 E 46TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-2417
Practice Address - Country:US
Practice Address - Phone:212-889-1171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-15
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY237264207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0168092Medicaid
NY2751471Medicaid
NY02884251Medicaid
NY02884251Medicaid
NY521A51Medicare PIN
NJ095704CX9Medicare PIN
NY2751471Medicaid