Healthcare Provider Details

I. General information

NPI: 1851498497
Provider Name (Legal Business Name): JACQUELIN VICTORIA DEATCHER NP, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3325 E MAIN STREET RD
ATTICA NY
14011-9506
US

IV. Provider business mailing address

3225B BROADWAY RD
ALEXANDER NY
14005-9760
US

V. Phone/Fax

Practice location:
  • Phone: 585-547-3849
  • Fax: 585-547-3351
Mailing address:
  • Phone: 585-547-3849
  • Fax: 585-547-3351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF303405-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: