Provider Demographics
NPI:1205335916
Name:JACKSON, JESSICA BERDETTE (LPN)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:BERDETTE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:BERDETTE
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:376 OWEGO RD
Mailing Address - Street 2:
Mailing Address - City:CANDOR
Mailing Address - State:NY
Mailing Address - Zip Code:13743-1645
Mailing Address - Country:US
Mailing Address - Phone:607-372-6591
Mailing Address - Fax:
Practice Address - Street 1:376 OWEGO RD
Practice Address - Street 2:
Practice Address - City:CANDOR
Practice Address - State:NY
Practice Address - Zip Code:13743-1645
Practice Address - Country:US
Practice Address - Phone:607-372-6591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY298757164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse