Provider Demographics
NPI:1609838358
Name:JACKSON, ILISSA D (PA-C)
Entity Type:Individual
Prefix:
First Name:ILISSA
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ILISSA
Other - Middle Name:
Other - Last Name:REIHS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1675 YORK AVE APT 8E
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-6738
Mailing Address - Country:US
Mailing Address - Phone:954-937-2579
Mailing Address - Fax:
Practice Address - Street 1:100 EAST 77TH ST
Practice Address - Street 2:LENOX HILL HOSPITAL-NSLIJHS
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075
Practice Address - Country:US
Practice Address - Phone:516-823-8010
Practice Address - Fax:516-823-8290
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103627363A00000X
NY23-015052363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant