Provider Demographics
NPI:1962671446
Name:JACKSON-HODGES, CHANDIA ELLEN (RPA-C)
Entity Type:Individual
Prefix:MRS
First Name:CHANDIA
Middle Name:ELLEN
Last Name:JACKSON-HODGES
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 LAKEVILLE RD
Mailing Address - Street 2:SUITE 206A
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1101
Mailing Address - Country:US
Mailing Address - Phone:718-470-7644
Mailing Address - Fax:
Practice Address - Street 1:410 LAKEVILLE RD
Practice Address - Street 2:SUITE 206A
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1101
Practice Address - Country:US
Practice Address - Phone:718-470-7644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011057363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant