Provider Demographics
NPI:1659666782
Name:JACKSON, VANESSA (LPN)
Entity Type:Individual
Prefix:MISS
First Name:VANESSA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:953 DEWEY AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14613-1640
Mailing Address - Country:US
Mailing Address - Phone:585-647-2576
Mailing Address - Fax:
Practice Address - Street 1:953 DEWEY AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14613-1640
Practice Address - Country:US
Practice Address - Phone:585-647-2576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY253799-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse