Provider Demographics
NPI:1811196488
Name:JACKSON, AVILA T (DPM)
Entity Type:Individual
Prefix:
First Name:AVILA
Middle Name:T
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:AVIA
Other - Middle Name:TERRELL
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:86-41 LEFFERTS BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418
Mailing Address - Country:US
Mailing Address - Phone:718-849-3338
Mailing Address - Fax:718-849-3166
Practice Address - Street 1:86-41 LEFFERTS BLVD.
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418
Practice Address - Country:US
Practice Address - Phone:718-849-3338
Practice Address - Fax:718-849-3166
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002248213EP1101X
NY006459213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine