Provider Demographics
NPI:1275764011
Name:JACKSON DERMATOLOGY PLLC
Entity Type:Organization
Organization Name:JACKSON DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:914-449-6970
Mailing Address - Street 1:55 GREENE AVE
Mailing Address - Street 2:SUITE 2D
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-1026
Mailing Address - Country:US
Mailing Address - Phone:914-449-4970
Mailing Address - Fax:
Practice Address - Street 1:55 GREENE AVE
Practice Address - Street 2:SUITE 2D
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-1026
Practice Address - Country:US
Practice Address - Phone:914-449-4970
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-28
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY177618174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty