Provider Demographics
NPI:1326483306
Name:JACKSON, MARCIA DAWN (LPN)
Entity Type:Individual
Prefix:MISS
First Name:MARCIA
Middle Name:DAWN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MISS
Other - First Name:MARCIA
Other - Middle Name:DAWN
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:5712 AVENUE H
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-1911
Mailing Address - Country:US
Mailing Address - Phone:917-853-9748
Mailing Address - Fax:347-673-5950
Practice Address - Street 1:5712 AVENUE H
Practice Address - Street 2:1ST FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-1911
Practice Address - Country:US
Practice Address - Phone:917-853-9748
Practice Address - Fax:347-673-5950
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-06
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY271850164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse