Provider Demographics
NPI:1528576899
Name:JACKSON, CORDERO (BSN RN)
Entity Type:Individual
Prefix:
First Name:CORDERO
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:BSN RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 DR MARTIN LUTHER KING JR BLVD APT 9
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102-1254
Mailing Address - Country:US
Mailing Address - Phone:917-657-8363
Mailing Address - Fax:
Practice Address - Street 1:624 DR MARTIN LUTHER KING JR BLVD APT 9
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-1254
Practice Address - Country:US
Practice Address - Phone:917-657-8363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-19
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY723035163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool