Basic Information
| Provider Information | |||||||||
| NPI: | 1609416940 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BISHOP | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 628 BLUE POINT RD | ||||||||
| Address2: | |||||||||
| City: | HOLTSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117421812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317084824 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 200 BELLE TERRE RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117771928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314761010 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2020 | ||||||||
| LastUpdateDate: | 06/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F344390 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.