Provider Demographics
NPI:1811283070
Name:JACKSON, PATTY S (LPN)
Entity type:Individual
Prefix:MRS
First Name:PATTY
Middle Name:S
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 ARROW WOOD PL
Mailing Address - Street 2:
Mailing Address - City:BALLSTON SPA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-4709
Mailing Address - Country:US
Mailing Address - Phone:518-899-1234
Mailing Address - Fax:
Practice Address - Street 1:139 ARROW WOOD PL
Practice Address - Street 2:
Practice Address - City:BALLSTON SPA
Practice Address - State:NY
Practice Address - Zip Code:12020-4709
Practice Address - Country:US
Practice Address - Phone:518-899-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-24
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY281024-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse