Healthcare Provider Details

I. General information

NPI: 1699274746
Provider Name (Legal Business Name): MARTHE JEHANE JACQUET RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARTHE JEHANE MISERE

II. Dates (important events)

Enumeration Date: 02/05/2018
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7925 WINCHESTER BLVD
QUEENS VILLAGE NY
11427-2128
US

IV. Provider business mailing address

31 ROBERTSON RD
LYNBROOK NY
11563-3730
US

V. Phone/Fax

Practice location:
  • Phone: 718-464-7500
  • Fax:
Mailing address:
  • Phone: 917-583-6335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number669097-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number406343
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: