Provider Demographics
NPI:1437197209
Name:JACKSON, JULIANNE (PA)
Entity Type:Individual
Prefix:
First Name:JULIANNE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JULIANNE
Other - Middle Name:
Other - Last Name:SUTTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1 E. NEW YORK AVE
Mailing Address - Street 2:4TH FLOOR ADMIN
Mailing Address - City:SOMERS POINT
Mailing Address - State:NJ
Mailing Address - Zip Code:08244
Mailing Address - Country:US
Mailing Address - Phone:609-653-3265
Mailing Address - Fax:609-926-4311
Practice Address - Street 1:4450 BLACK HORSE PIKE STE 3972
Practice Address - Street 2:
Practice Address - City:MAYS LANDING
Practice Address - State:NJ
Practice Address - Zip Code:08330-3117
Practice Address - Country:US
Practice Address - Phone:609-365-6217
Practice Address - Fax:609-653-1439
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP001302363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ085808DR7Medicare PIN
NJQ29540Medicare UPIN