Provider Demographics
NPI:1629009576
Name:JACKSON, JERREYLL TRAVIS (MD)
Entity Type:Individual
Prefix:
First Name:JERREYLL
Middle Name:TRAVIS
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4604 31ST AVE
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11103-1842
Mailing Address - Country:US
Mailing Address - Phone:212-889-1171
Mailing Address - Fax:
Practice Address - Street 1:4604 31ST AVE
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11103-1842
Practice Address - Country:US
Practice Address - Phone:212-889-1171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07982400207W00000X
CT043661207W00000X
NY237264207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2751471Medicaid
NY02884251Medicaid
NJ0168092Medicaid
NY2751471Medicaid
NY521A51Medicare PIN
NYH37399Medicare UPIN
NJ095704T64Medicare PIN