Provider Demographics
NPI:1932320124
Name:JACKSON, GEORGE (TECHNOLOGIST)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:TECHNOLOGIST
Other - Prefix:
Other - First Name:GEORGE
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MT
Mailing Address - Street 1:645 DECATUR STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11233
Mailing Address - Country:US
Mailing Address - Phone:718-443-0204
Mailing Address - Fax:
Practice Address - Street 1:130 WEST KINGSBRIDGE ROAD
Practice Address - Street 2:BRONX V.A. MEDICAL CENTER
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-3904
Practice Address - Country:US
Practice Address - Phone:718-584-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NONE246QH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QH0000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyHematology