Basic Information
| Provider Information | |||||||||
| NPI: | 1194328872 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | PATRICE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 S B B KING BLVD # 100 | ||||||||
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| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381032626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014361381 | ||||||||
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| Practice Location | |||||||||
| Address1: | 21002 HOLLIS AVE | ||||||||
| Address2: | |||||||||
| City: | QUEENS VILLAGE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114291436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2402520370 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2020 | ||||||||
| LastUpdateDate: | 07/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 310015 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.