1275864498 NPI number — MRS. MARGUERITE ELIZABETH JACKSON LPN

Table of content: MRS. MARGUERITE ELIZABETH JACKSON LPN (NPI 1275864498)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275864498 NPI number — MRS. MARGUERITE ELIZABETH JACKSON LPN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
MARGUERITE
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LOREN
Provider Other First Name:
MARGUERITE
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1275864498
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2685 RIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ONTARIO
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14519-9560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-506-6731
Provider Business Mailing Address Fax Number:
585-336-4895

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2685 RIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ONTARIO
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14519-9560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-506-6731
Provider Business Practice Location Address Fax Number:
585-336-4895
Provider Enumeration Date:
01/28/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 164W00000X , with the licence number:  144811-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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