Healthcare Provider Details

I. General information

NPI: 1295367613
Provider Name (Legal Business Name): JACQUELINE ANN COMELLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2020
Last Update Date: 02/05/2020
Certification Date: 02/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1439 BUFFALO ST
OLEAN NY
14760-1140
US

IV. Provider business mailing address

5586 WOODCREST AVE LOT 2
FREDONIA NY
14063-1539
US

V. Phone/Fax

Practice location:
  • Phone: 716-375-4747
  • Fax:
Mailing address:
  • Phone: 716-951-0763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP103851
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: