Provider Demographics
NPI:1386767440
Name:JACKSON, JENNY (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JENNY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 WILLIS AVE
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-2432
Mailing Address - Country:US
Mailing Address - Phone:516-742-1730
Mailing Address - Fax:516-873-1641
Practice Address - Street 1:243 WILLIS AVE
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501
Practice Address - Country:US
Practice Address - Phone:516-742-1730
Practice Address - Fax:516-873-1641
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011580363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant