Provider Demographics
NPI:1710174040
Name:JACKSON, AVRIL DELORES (LPN)
Entity Type:Individual
Prefix:MISS
First Name:AVRIL
Middle Name:DELORES
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 1:3310 AVE H
Mailing Address - Street 2:APT 2L
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210
Mailing Address - Country:US
Mailing Address - Phone:718-434-4659
Mailing Address - Fax:
Practice Address - Street 1:3310 AVE H
Practice Address - Street 2:APT 2L
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210
Practice Address - Country:US
Practice Address - Phone:718-434-4659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2789001164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02667458Medicaid