Provider Demographics
NPI:1740751825
Name:JACKSON, ASHLEY ROCHELLE
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:ROCHELLE
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 1:10416 223RD ST
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429-2157
Mailing Address - Country:US
Mailing Address - Phone:347-293-3119
Mailing Address - Fax:718-799-1049
Practice Address - Street 1:6321 NEW UTRECHT AVE FL 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-5425
Practice Address - Country:US
Practice Address - Phone:212-687-7464
Practice Address - Fax:718-799-1049
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY655416164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse