Healthcare Provider Details

I. General information

NPI: 1336964873
Provider Name (Legal Business Name): JACQUELINE LI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462 1ST AVE
NEW YORK NY
10016-9196
US

IV. Provider business mailing address

2881 NOSTRAND AVE APT 3E
BROOKLYN NY
11229-1984
US

V. Phone/Fax

Practice location:
  • Phone: 212-562-3917
  • Fax: 212-263-8640
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number311975
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: