Provider Demographics
NPI:1538155973
Name:JACKSON, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 1ST AVE
Mailing Address - Street 2:7TH FL.
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-3214
Mailing Address - Country:US
Mailing Address - Phone:212-263-7567
Mailing Address - Fax:
Practice Address - Street 1:660 1ST AVE
Practice Address - Street 2:7TH FL.
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-3214
Practice Address - Country:US
Practice Address - Phone:212-263-7567
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001902231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPENDINGMedicaid
NYPENDINGMedicaid