Provider Demographics
NPI:1962680934
Name:NEW HAVEN PEDIATRIC & ADOLESCENT MEDICAL SERV
Entity Type:Organization
Organization Name:NEW HAVEN PEDIATRIC & ADOLESCENT MEDICAL SERV
Other - Org Name:TAMIKO V JACKSON MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-906-3854
Mailing Address - Street 1:1423 CHAPEL ST
Mailing Address - Street 2:UNIT 2B
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511
Mailing Address - Country:US
Mailing Address - Phone:203-752-0706
Mailing Address - Fax:203-772-0387
Practice Address - Street 1:1423 CHAPEL ST
Practice Address - Street 2:UNIT 2B
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511
Practice Address - Country:US
Practice Address - Phone:203-752-0706
Practice Address - Fax:203-772-0387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-01
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0136872208000000X
CT0002815363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F68041Medicare UPIN