Provider Demographics
NPI:1487844973
Name:JACKSON, LISA NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:NICOLE
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 1:354 E 91ST ST
Mailing Address - Street 2:APT 1805
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-5354
Mailing Address - Country:US
Mailing Address - Phone:312-213-6402
Mailing Address - Fax:
Practice Address - Street 1:89-06 135TH ST
Practice Address - Street 2:ROOM 6A
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11418
Practice Address - Country:US
Practice Address - Phone:718-206-6808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY60 245188207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology