Provider Demographics
NPI:1780813816
Name:BOSWORTH, JACKIE M (MD)
Entity type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:M
Last Name:BOSWORTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W 92ND ST
Mailing Address - Street 2:APT. 5A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-7432
Mailing Address - Country:US
Mailing Address - Phone:212-787-4909
Mailing Address - Fax:
Practice Address - Street 1:1 BROOKDALE PLZ
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-3139
Practice Address - Country:US
Practice Address - Phone:718-240-8075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-10
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP569912084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry