Provider Demographics
NPI:1619368511
Name:JACKSON, JANNIEVE SR (MA)
Entity Type:Individual
Prefix:MS
First Name:JANNIEVE
Middle Name:
Last Name:JACKSON
Suffix:SR
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:288 CROWN ST
Mailing Address - Street 2:APT. 5H
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-3026
Mailing Address - Country:US
Mailing Address - Phone:718-636-0132
Mailing Address - Fax:347-787-2901
Practice Address - Street 1:288 CROWN ST
Practice Address - Street 2:APT. 5H
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-3026
Practice Address - Country:US
Practice Address - Phone:718-636-0132
Practice Address - Fax:347-787-2901
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-12
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist