Provider Demographics
NPI:1194493932
Name:JACKSON, BERNICE (NP)
Entity type:Individual
Prefix:MRS
First Name:BERNICE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:BERNICE
Other - Middle Name:
Other - Last Name:BUTTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1434 WILLIAMSBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2507
Mailing Address - Country:US
Mailing Address - Phone:718-618-0401
Mailing Address - Fax:
Practice Address - Street 1:212 5TH AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-6408
Practice Address - Country:US
Practice Address - Phone:718-299-7295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-04
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310387363LA2200X
NY405214363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health