Provider Demographics
NPI:1851595334
Name:JACKSON, CARRIE ROSE KLOTZ (MD)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:ROSE KLOTZ
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:ROSE
Other - Last Name:KLOTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:134 HOMER AVE
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-1206
Mailing Address - Country:US
Mailing Address - Phone:410-409-5844
Mailing Address - Fax:
Practice Address - Street 1:134 HOMER AVE
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-1206
Practice Address - Country:US
Practice Address - Phone:410-409-5844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY256859207P00000X
TNMD0000045187207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine