Provider Demographics
NPI:1477845725
Name:JACKSON, ANNA ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:ELIZABETH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 E 161ST ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-3535
Mailing Address - Country:US
Mailing Address - Phone:917-219-5720
Mailing Address - Fax:
Practice Address - Street 1:305 E 161ST ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-3535
Practice Address - Country:US
Practice Address - Phone:917-219-5720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-04
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261306207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine