Provider Demographics
NPI:1841341054
Name:JACKSON, MARGARET ALENE (MD)
Entity type:Individual
Prefix:
First Name:MARGARET
Middle Name:ALENE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MICHELLE ST
Mailing Address - Street 2:
Mailing Address - City:MONROE TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08831-8620
Mailing Address - Country:US
Mailing Address - Phone:732-723-1560
Mailing Address - Fax:
Practice Address - Street 1:2698 FREDERICK DOUGLASS BLVD
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10030-1219
Practice Address - Country:US
Practice Address - Phone:212-939-8966
Practice Address - Fax:212-939-8973
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY156733-1208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01115333Medicaid
04F611Medicare ID - Type Unspecified
NY01115333Medicaid