Provider Demographics
NPI:1578197588
Name:JACKSON, STARR SHALAE
Entity Type:Individual
Prefix:
First Name:STARR
Middle Name:SHALAE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303-2628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2627 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-4344
Practice Address - Country:US
Practice Address - Phone:646-533-0990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-28
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY345211163WG0000X, 208VP0014X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine