Provider Demographics
NPI:1396834990
Name:JACKSON, ROBERT (FNP)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:853 LONGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459-4000
Mailing Address - Country:US
Mailing Address - Phone:212-535-9779
Mailing Address - Fax:212-535-7699
Practice Address - Street 1:853 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459-4000
Practice Address - Country:US
Practice Address - Phone:718-588-4460
Practice Address - Fax:718-893-5493
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF331987-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner