Provider Demographics
NPI:1396024733
Name:JACKSON RICKETTS, ANNETT (LPN)
Entity Type:Individual
Prefix:
First Name:ANNETT
Middle Name:
Last Name:JACKSON RICKETTS
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 1:1024 BAY 30TH ST FL 1
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-1842
Mailing Address - Country:US
Mailing Address - Phone:347-339-9016
Mailing Address - Fax:
Practice Address - Street 1:1024 BAY 30TH ST FL 1
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-1842
Practice Address - Country:US
Practice Address - Phone:347-339-9016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-16
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY304647164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse