Provider Demographics
NPI:1366115412
Name:JACKSON DAVID, GRACENELL PHILEEN
Entity type:Individual
Prefix:
First Name:GRACENELL
Middle Name:PHILEEN
Last Name:JACKSON DAVID
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:784 LINDEN BLVD APT 2C
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-3535
Mailing Address - Country:US
Mailing Address - Phone:718-781-2041
Mailing Address - Fax:
Practice Address - Street 1:784 LINDEN BLVD APT 2C
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-3535
Practice Address - Country:US
Practice Address - Phone:718-781-2041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225CX0006XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorOrientation and Mobility Training Provider