Provider Demographics
NPI:1639369044
Name:JACKOWSKI, KIM ALICIA (RN)
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:ALICIA
Last Name:JACKOWSKI
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 CACKLETOWN RD
Mailing Address - Street 2:
Mailing Address - City:NARROWSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:12764-5805
Mailing Address - Country:US
Mailing Address - Phone:845-252-3797
Mailing Address - Fax:
Practice Address - Street 1:57 CACKLETOWN RD
Practice Address - Street 2:
Practice Address - City:NARROWSBURG
Practice Address - State:NY
Practice Address - Zip Code:12764-5805
Practice Address - Country:US
Practice Address - Phone:845-252-3797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY543430-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse