Provider Demographics
NPI:1992005060
Name:JACKSON, VICTORIA ELAINE
Entity Type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:ELAINE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13224-1940
Mailing Address - Country:US
Mailing Address - Phone:315-313-0515
Mailing Address - Fax:
Practice Address - Street 1:1501 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13224-1940
Practice Address - Country:US
Practice Address - Phone:315-313-0515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-23
Last Update Date:2010-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10296863164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10296863Medicare PIN