Jackson, Jerreyll Travis

Jackson, Jerreyll Travis is an sole proprietor health care provider with primary practice located at 4604 31St Ave , Long Island City NY 11103-1842. He recently has only one registered license in Allopathic & Osteopathic Physicians / Ophthalmology, which is considered as his primary health care specialty. Jackson, Jerreyll Travis can be contacted via phone (212) 889-1171.

Contact Information

Primary practice address
4604 31St Ave Long Island City NY 11103-1842
Phone: (212) 889-1171
Fax:
Website:
Map and Directions

Health care specialties

SpecialtyCodeLicense #State
Allopathic & Osteopathic Physicians / Ophthalmology 207W00000X 25MA07982400 New Jersey
Allopathic & Osteopathic Physicians / Ophthalmology 207W00000X 043661 Connecticut
Allopathic & Osteopathic Physicians / Ophthalmology 207W00000X 237264 New York

Profile Details

NPI number 1629009576
LBN Legal business name Jackson, Jerreyll Travis
Credentials Doctor of Medicine (MD)
Entity Individual
Sole proprietor 1 Yes
Enumeration date Jul 6th, 2006
Last updated Dec 8th, 2008 - about 17 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1629009576 NPPES
New York MEDICAID 2751471
New York MEDICAID 02884251
New York MEDICAID 0168092

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