Provider Demographics
NPI:1821256926
Name:JACKSON, STEVON COLLINSWORTH (LICENSED PRACTICAL N)
Entity Type:Individual
Prefix:MR
First Name:STEVON
Middle Name:COLLINSWORTH
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LICENSED PRACTICAL N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 HIGHLAND AVENUE
Mailing Address - Street 2:APT 2N
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10705
Mailing Address - Country:US
Mailing Address - Phone:914-966-1094
Mailing Address - Fax:914-966-1094
Practice Address - Street 1:101 HIGHLAND AVENUE
Practice Address - Street 2:APT 2N
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10705
Practice Address - Country:US
Practice Address - Phone:914-966-1094
Practice Address - Fax:914-966-1094
Is Sole Proprietor?:No
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2862591164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse