Provider Demographics
NPI:1568693414
Name:JACKSON ASMOAH
Entity Type:Organization
Organization Name:JACKSON ASMOAH
Other - Org Name:JACKSON ASAMOAH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RN
Authorized Official - Prefix:MR
Authorized Official - First Name:JACKSON
Authorized Official - Middle Name:
Authorized Official - Last Name:ASAMOAH
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:347-558-3176
Mailing Address - Street 1:1111 GERARD AVE APT 1A
Mailing Address - Street 2:1111 GERARD AVE APT 1A
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10452-8821
Mailing Address - Country:US
Mailing Address - Phone:347-558-3176
Mailing Address - Fax:
Practice Address - Street 1:1111 GERARD AVE APT 1A
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10452
Practice Address - Country:US
Practice Address - Phone:347-558-3176
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-27
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY571561-1282E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282E00000XHospitalsLong Term Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY123456Medicaid