Provider Demographics
NPI:1720458904
Name:ANDERSON, JACKLIN (RN)
Entity Type:Individual
Prefix:
First Name:JACKLIN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 FERGERSON PARK
Mailing Address - Street 2:
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-2323
Mailing Address - Country:US
Mailing Address - Phone:315-727-4812
Mailing Address - Fax:
Practice Address - Street 1:321 W ONONDAGA ST
Practice Address - Street 2:SUITE 201
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-3207
Practice Address - Country:US
Practice Address - Phone:315-478-0610
Practice Address - Fax:315-478-2510
Is Sole Proprietor?:No
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6960321163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse