Provider Demographics
NPI:1548298953
Name:JACKSON, CRYSTAL L (PA C)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:L
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 1:61 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-1900
Mailing Address - Country:US
Mailing Address - Phone:913-762-8344
Mailing Address - Fax:973-762-1626
Practice Address - Street 1:61 1ST ST
Practice Address - Street 2:
Practice Address - City:SOUTH ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07079-1900
Practice Address - Country:US
Practice Address - Phone:973-762-8344
Practice Address - Fax:973-762-1626
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00046700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP3404235OtherOXFORD
P87755Medicare UPIN
NJ08604856HMedicare ID - Type Unspecified