Healthcare Provider Details

I. General information

NPI: 1568860633
Provider Name (Legal Business Name): JAQUAYJA REBECCA MAYZCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2014
Last Update Date: 12/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2631 MERRICK RD SUITE 202
BELLMORE NY
11710-5730
US

IV. Provider business mailing address

22 COX PLACE APT 3
BROOKLYN NY
11208
US

V. Phone/Fax

Practice location:
  • Phone: 516-590-7575
  • Fax:
Mailing address:
  • Phone: 347-545-9709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: