Provider Demographics
NPI:1649583733
Name:JACKSON, CORA
Entity Type:Individual
Prefix:
First Name:CORA
Middle Name:
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 1:263 EASTERN PKWY
Mailing Address - Street 2:APT 6J
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-6371
Mailing Address - Country:US
Mailing Address - Phone:718-757-7918
Mailing Address - Fax:
Practice Address - Street 1:263 EASTERN PKWY
Practice Address - Street 2:APT 6J
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-6371
Practice Address - Country:US
Practice Address - Phone:718-757-7918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-19
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY319515-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse