NPIMap

Individual provider Active NPI

Jerreyll Travis Jackson, MD

  • Ophthalmology Physician
  • Long Island City, NY
National Provider Identifier
1629009576
Registry record updated Dec 8, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Ophthalmology PhysicianTaxonomy code 207W00000X
License
237264 Issued in NY
Practice address
4604 31St Ave
Long Island City, NY 11103-1842
Phone
(212) 889-1171
NPI assigned
Jul 6, 2006
Sex
Male
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Dec 8, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Ophthalmology Physician 207W00000X 25MA07982400 NJ
Ophthalmology Physician 207W00000X 043661 CT
Ophthalmology Physician 207W00000X 237264 NY Primary

Addresses

Primary practice location

4604 31St Ave
Long Island City, NY 11103-1842

Mailing address

4604 31St Ave
Long Island City, NY 11103-1842
Phone (212) 889-1171

Other identifiers 3

IdentifierTypeStateIssuer
2751471MedicaidNY
02884251MedicaidNY
0168092MedicaidNJ

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
043661CTMDOphthalmology Physician
25MA07982400NJMDOphthalmology Physician
237264NYMDOphthalmology Physician

Practice roles

OrganizationSpecialtyStatusNew patients
New Jersey Refractive Professional Corporation Ophthalmology Past Accepting new patients
Ayman Z. Matta, M.D., P.C. Ophthalmology Past Accepting new patients
Boro Medical, P.C. Ophthalmology Past Accepting new patients
Sharpest Vision Refractive Surgery PC Ophthalmology Past Accepting new patients
Sajid Malik MD PC Ophthalmology Past Accepting new patients
Greenwich Eye Center Ophthalmology Past Accepting new patients

Organizations & group practices 6

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1152144000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1228694400000",
    "number": "1629009576",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4604 31ST AVE",
            "city": "LONG ISLAND CITY",
            "state": "NY",
            "postal_code": "111031842",
            "telephone_number": "212-889-1171"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4604 31ST AVE",
            "city": "LONG ISLAND CITY",
            "state": "NY",
            "postal_code": "111031842",
            "telephone_number": "212-889-1171"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "JERREYLL",
        "middle_name": "TRAVIS",
        "credential": "MD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-07-06",
        "last_updated": "2008-12-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207W00000X",
            "taxonomy_group": "",
            "desc": "Ophthalmology",
            "state": "NJ",
            "license": "25MA07982400",
            "primary": false
        },
        {
            "code": "207W00000X",
            "taxonomy_group": "",
            "desc": "Ophthalmology",
            "state": "CT",
            "license": "043661",
            "primary": false
        },
        {
            "code": "207W00000X",
            "taxonomy_group": "",
            "desc": "Ophthalmology",
            "state": "NY",
            "license": "237264",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2751471",
            "state": "NY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "02884251",
            "state": "NY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0168092",
            "state": "NJ"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Long Island City, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 8, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.