Provider Demographics
NPI:1780034835
Name:JACKSON, YAZMYNE
Entity Type:Individual
Prefix:
First Name:YAZMYNE
Middle Name:
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 1:157 W 117TH ST
Mailing Address - Street 2:APT 2C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026-2247
Mailing Address - Country:US
Mailing Address - Phone:347-741-0747
Mailing Address - Fax:
Practice Address - Street 1:157 W 117TH ST
Practice Address - Street 2:APT 2C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10026-2247
Practice Address - Country:US
Practice Address - Phone:347-741-0747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant