Provider Demographics
NPI:1295033322
Name:JACKSON, DEBRA (LPN)
Entity Type:Individual
Prefix:PROF
First Name:DEBRA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:PROF
Other - First Name:DEBRA
Other - Middle Name:LORETTA
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:1625 E 54TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-3919
Mailing Address - Country:US
Mailing Address - Phone:718-915-0351
Mailing Address - Fax:
Practice Address - Street 1:1625 E 54TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-3919
Practice Address - Country:US
Practice Address - Phone:718-915-0351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-14
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY236779 9164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse