Individual
MS. TERESA ALICE JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MSED
Contact information
Practice address
41 GREEN ST, VALLEY STREAM, NY 11580-4815
(516) 285-6388
(516) 285-6388
Mailing address
41 GREEN ST, VALLEY STREAM, NY 11580-4815
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
486110931
NY
171W00000X
Contractor
486112931
NY
171W00000X
Contractor
Primary
717251962
NY
Other
Enumeration date
06/11/2012
Last updated
06/11/2012
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