Provider Demographics
NPI:1457331209
Name:JACKSON, HARRY
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 NETHERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-4801
Mailing Address - Country:US
Mailing Address - Phone:718-379-4444
Mailing Address - Fax:
Practice Address - Street 1:140 ALCOTT PL
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-4302
Practice Address - Country:US
Practice Address - Phone:718-379-4444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY110153173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00196483Medicaid
NYC10751Medicare UPIN
NY511301Medicare PIN