Provider Demographics
NPI:1326306184
Name:JACKSON, CAROLYN CHANG (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:CHANG
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:DR
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:CHANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD, MPH
Mailing Address - Street 1:1275 YORK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-6007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1275 YORK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-6007
Practice Address - Country:US
Practice Address - Phone:212-639-5966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY264002208000000X, 2080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology