Provider Demographics
NPI:1427360536
Name:JACKSON, REBECCA SUZANNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:SUZANNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 SEAVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-3436
Mailing Address - Country:US
Mailing Address - Phone:718-226-9877
Mailing Address - Fax:
Practice Address - Street 1:291 MAIN ST
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:NJ
Practice Address - Zip Code:07928-2442
Practice Address - Country:US
Practice Address - Phone:973-635-9091
Practice Address - Fax:973-635-9087
Is Sole Proprietor?:No
Enumeration Date:2010-07-06
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
NJ22DIO24698001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program