Provider Demographics
NPI:1699273789
Name:JACKSON, ANITA ANN (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2853 WEBB AVE BRONX NY 10468
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-2154
Mailing Address - Country:US
Mailing Address - Phone:718-796-3503
Mailing Address - Fax:
Practice Address - Street 1:2853 WEBB AVE BRONX NY 10468
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-2154
Practice Address - Country:US
Practice Address - Phone:718-796-3503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-24
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY359701-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse