Provider Demographics
NPI:1700034287
Name:JACKSON, ROSA LEE (LPN)
Entity Type:Individual
Prefix:MS
First Name:ROSA
Middle Name:LEE
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 1:547 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-3725
Mailing Address - Country:US
Mailing Address - Phone:516-546-2674
Mailing Address - Fax:
Practice Address - Street 1:547 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-3725
Practice Address - Country:US
Practice Address - Phone:516-546-2674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200042164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse