Provider Demographics
NPI:1447789565
Name:ANDERSON, JACKIE MAE (DO)
Entity Type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:MAE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MS
Other - First Name:JACKIE
Other - Middle Name:MAE
Other - Last Name:GRIMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVENUE BOX 655
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-8655
Mailing Address - Country:US
Mailing Address - Phone:585-273-4398
Mailing Address - Fax:
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-4200
Practice Address - Country:US
Practice Address - Phone:585-275-9555
Practice Address - Fax:585-473-3516
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT018082207PE0004X
NY312232363AM0700X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical