Healthcare Provider Details

I. General information

NPI: 1205757218
Provider Name (Legal Business Name): JACQUELINE IVERSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 FORT HILL DR
LLOYD HARBOR NY
11743-9768
US

IV. Provider business mailing address

35 FORT HILL DR
LLOYD HARBOR NY
11743-9768
US

V. Phone/Fax

Practice location:
  • Phone: 201-417-7765
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number037230
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: