Healthcare Provider Details

I. General information

NPI: 1508213992
Provider Name (Legal Business Name): OLGA JOSEPHINE JACQUES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2016
Last Update Date: 09/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 E 188TH ST
BRONX NY
10458-5302
US

IV. Provider business mailing address

260 E 188TH ST
BRONX NY
10458-5302
US

V. Phone/Fax

Practice location:
  • Phone: 718-960-9000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number299595
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: