Provider Demographics
NPI:1942638606
Name:JACKSON, DIPAN KAUR (NP)
Entity Type:Individual
Prefix:
First Name:DIPAN
Middle Name:KAUR
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1978 CROMPOND ROAD
Mailing Address - Street 2:ST 201
Mailing Address - City:CORTLAND MANOR
Mailing Address - State:NY
Mailing Address - Zip Code:10567
Mailing Address - Country:US
Mailing Address - Phone:646-539-0945
Mailing Address - Fax:
Practice Address - Street 1:1978 CROMPOND ROAD
Practice Address - Street 2:ST 201
Practice Address - City:CORTLAND MANOR
Practice Address - State:NY
Practice Address - Zip Code:10567
Practice Address - Country:US
Practice Address - Phone:646-539-0945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-16
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY338360363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner