Provider Demographics
NPI:1316311343
Name:JACKMAN, MIGNON
Entity type:Individual
Prefix:
First Name:MIGNON
Middle Name:
Last Name:JACKMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 DE GRASSE ST
Mailing Address - Street 2:
Mailing Address - City:FORDS
Mailing Address - State:NJ
Mailing Address - Zip Code:08863-1342
Mailing Address - Country:US
Mailing Address - Phone:732-754-1576
Mailing Address - Fax:
Practice Address - Street 1:42 DE GRASSE ST
Practice Address - Street 2:
Practice Address - City:FORDS
Practice Address - State:NJ
Practice Address - Zip Code:08863-1342
Practice Address - Country:US
Practice Address - Phone:732-754-1576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-13
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY690676174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist