Provider Demographics
NPI:1265411474
Name:HARRY JACKSON MD PC
Entity type:Organization
Organization Name:HARRY JACKSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETER
Authorized Official - Prefix:
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-379-4444
Mailing Address - Street 1:2600 NETHERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-4801
Mailing Address - Country:US
Mailing Address - Phone:718-379-4444
Mailing Address - Fax:
Practice Address - Street 1:140 ALCOTT PL
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-4302
Practice Address - Country:US
Practice Address - Phone:718-379-4444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-16
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY511301173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00196483Medicaid
NY511301Medicare PIN
NY00196483Medicaid