Provider Demographics
NPI:1558367540
Name:JACKUS, KIMBERLY A (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:JACKUS
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:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:MILLTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08850-0280
Mailing Address - Country:US
Mailing Address - Phone:800-738-1659
Mailing Address - Fax:
Practice Address - Street 1:3127 41ST ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-3901
Practice Address - Country:US
Practice Address - Phone:718-721-6989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY186183-1207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02111686Medicaid
F79001Medicare UPIN
NY07J821Medicare ID - Type Unspecified