Provider Demographics
NPI:1518229707
Name:JACKSON, LORETTA FRANCES (MSED)
Entity Type:Individual
Prefix:MRS
First Name:LORETTA
Middle Name:FRANCES
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 240
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10475-0240
Mailing Address - Country:US
Mailing Address - Phone:917-504-7948
Mailing Address - Fax:
Practice Address - Street 1:100-21G DEKRUIF PLACE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-0240
Practice Address - Country:US
Practice Address - Phone:917-504-7948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY643324051174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist