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General NPI Number Information
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NPI Number | 1093304594
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Entity Type | Individual
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Provider Name | ALLISON OLIVIA JAEKLE
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Gender | Female
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Dates
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Enumeration Date | 01/11/2021
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Last Update Date | 09/27/2022
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Provider Practice Location Address
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Address Line | 7901 4TH AVE STE A20
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City | BROOKLYN
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State | NY
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Zip | 11209-3957
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Country | US
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Telephone | 718-491-5800
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Fax | 718-748-2151
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Provider Business Mailing Address
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Address Line | 119 PARK AVE
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City | LAKE RONKONKOMA
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State | NY
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Zip | 11779-1729
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Country | US
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Telephone | 631-557-3043
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 00000000000
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 026397-01
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License Number State | NY
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