Provider Demographics
NPI:1265707368
Name:JACKSON, ROBERT H (RPA-C)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:H
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 PROSPECT PARK W
Mailing Address - Street 2:BSMT APT
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-6092
Mailing Address - Country:US
Mailing Address - Phone:718-369-1428
Mailing Address - Fax:
Practice Address - Street 1:2601 OCEAN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-7745
Practice Address - Country:US
Practice Address - Phone:718-616-5381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-21
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015132363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant