Provider Demographics
NPI:1376012757
Name:JACKSON, ARIELLE S (LPN)
Entity Type:Individual
Prefix:
First Name:ARIELLE
Middle Name:S
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 HEMPSTEAD AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-3404
Mailing Address - Country:US
Mailing Address - Phone:716-831-7877
Mailing Address - Fax:831-866-6666
Practice Address - Street 1:244 HEMPSTEAD AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-3404
Practice Address - Country:US
Practice Address - Phone:716-831-7877
Practice Address - Fax:831-866-6666
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY333364164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY333364OtherLICENSED PRACTICAL NURSE