Provider Demographics
NPI:1831546688
Name:JACKSON, QUIRSTEN NICHOLE-MARIE
Entity type:Individual
Prefix:
First Name:QUIRSTEN
Middle Name:NICHOLE-MARIE
Last Name:JACKSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 SUFFERN PLACE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901
Mailing Address - Country:US
Mailing Address - Phone:845-357-4500
Mailing Address - Fax:845-357-5039
Practice Address - Street 1:3005 WHISPERING HLS
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:NY
Practice Address - Zip Code:10918-1545
Practice Address - Country:US
Practice Address - Phone:845-630-9767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-23
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY849585163W00000X
NY315353164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse