Provider Demographics
NPI:1508277955
Name:JACKSON, ALICIA (RN,DOULA)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN,DOULA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 CAPEN BLVD
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-3013
Mailing Address - Country:US
Mailing Address - Phone:716-587-2208
Mailing Address - Fax:
Practice Address - Street 1:191 CAPEN BLVD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-3013
Practice Address - Country:US
Practice Address - Phone:716-597-2208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-19
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374J00000X
NY736029163W00000X
NY311702164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No374J00000XNursing Service Related ProvidersDoulaGroup - Multi-Specialty
No164W00000XNursing Service ProvidersLicensed Practical Nurse