MEDICARE: JACQUELINE SHALL-MCCUMISKEY, PSY.D. MINDFUL PRACTICE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist

General Provider Information

NPI Number	:	1104699974
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACQUELINE SHALL-MCCUMISKEY, PSY.D. MINDFUL PRACTICE

Provider Business Mailing Address
First Line	:	1675 RICHMOND RD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10304-2317
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1675 RICHMOND RD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10304-2317
Country	:	US
Telephone Number	:	646-479-8068
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JACQUELINE SHALL-MCCUMISKEY
Credential	:
Telephone Number	:	646-479-8068

Provider Enumeration Date	:	11/03/2023
Last Update Date	:	03/03/2025

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