Provider Demographics
NPI:1689309361
Name:JACKSON, ROXANN (LPN)
Entity Type:Individual
Prefix:MS
First Name:ROXANN
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 1:355 W PLEASANTVIEW AVE APT 410
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1052
Mailing Address - Country:US
Mailing Address - Phone:954-479-9657
Mailing Address - Fax:
Practice Address - Street 1:355 W PLEASANTVIEW AVE APT 410
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1052
Practice Address - Country:US
Practice Address - Phone:954-479-9657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY344293164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse