Provider Demographics
NPI:1841594082
Name:MORGAN, JACKIE J (LPN)
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:J
Last Name:MORGAN
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 1:903 DAVIS HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:NEWARK VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:13811-2720
Mailing Address - Country:US
Mailing Address - Phone:607-821-2775
Mailing Address - Fax:
Practice Address - Street 1:435 GLENWOOD RD
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-1606
Practice Address - Country:US
Practice Address - Phone:607-763-3684
Practice Address - Fax:607-763-3363
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY269066-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY122296668Medicaid