Healthcare Provider Details

I. General information

NPI: 1245612472
Provider Name (Legal Business Name): JACQUELYN FIBER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2015
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

546 EASTERN PKWY
BROOKLYN NY
11225-1604
US

IV. Provider business mailing address

800 AXINN AVE
GARDEN CITY NY
11530-2139
US

V. Phone/Fax

Practice location:
  • Phone: 718-604-4800
  • Fax: 718-604-4828
Mailing address:
  • Phone: 646-680-2888
  • Fax: 516-542-5556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number009278
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: