Basic Information
| Provider Information | |||||||||
| NPI: | 1699274746 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACQUET | ||||||||
| FirstName: | MARTHE | ||||||||
| MiddleName: | JEHANE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MISERE | ||||||||
| OtherFirstName: | MARTHE | ||||||||
| OtherMiddleName: | JEHANE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 18117 143RD AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD GARDENS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114133014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9175836335 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7925 WINCHESTER BLVD | ||||||||
| Address2: | |||||||||
| City: | QUEENS VILLAGE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114272128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184647500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2018 | ||||||||
| LastUpdateDate: | 02/05/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0809X | 669097-1 | NY | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult |
No ID Information.