Provider Demographics
NPI:1700116993
Name:JACKSON, ROSEANNE JOHNSON
Entity Type:Individual
Prefix:MS
First Name:ROSEANNE
Middle Name:JOHNSON
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:ROSEANNE
Other - Middle Name:LEE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2128 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14207-1910
Mailing Address - Country:US
Mailing Address - Phone:716-874-4500
Mailing Address - Fax:
Practice Address - Street 1:2128 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14207-1910
Practice Address - Country:US
Practice Address - Phone:716-874-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-11
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NY083560-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400328322Medicare PIN