Provider Demographics
NPI:1528380250
Name:JACKSON, BERNADETTE (RN)
Entity Type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 BERTHA DR
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-5052
Mailing Address - Country:US
Mailing Address - Phone:516-223-2932
Mailing Address - Fax:
Practice Address - Street 1:3420 BERTHA DR
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-5052
Practice Address - Country:US
Practice Address - Phone:516-223-2932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-22
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY387144163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY387144OtherNYS NURSING LICENSE RN