Provider Demographics
NPI:1275864498
Name:JACKSON, MARGUERITE ELIZABETH (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MARGUERITE
Middle Name:ELIZABETH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:MARGUERITE
Other - Middle Name:ELIZABETH
Other - Last Name:LOREN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:2685 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:NY
Mailing Address - Zip Code:14519-9560
Mailing Address - Country:US
Mailing Address - Phone:585-506-6731
Mailing Address - Fax:585-336-4895
Practice Address - Street 1:2685 RIDGE RD
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:NY
Practice Address - Zip Code:14519-9560
Practice Address - Country:US
Practice Address - Phone:585-506-6731
Practice Address - Fax:585-336-4895
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-28
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY144811-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse