MEDICARE: JACKELINE TOMAS APN

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	363L00000X	Nurse Practitioner	26NJ00740200	NJ

General Provider Information

NPI Number	:	1184143505
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKELINE TOMAS APN

Provider Business Mailing Address
First Line	:	498 PINE HILL RD
Second Line	:
City	:	LEONIA
State	:	NJ
Zip	:	07605-1422
Country	:	US
Telephone Number	:	201-755-0793
Fax Number	:

Provider Business Practice Location Address
First Line	:	777 TERRACE AVE STE 311
Second Line	:
City	:	HASBROUCK HEIGHTS
State	:	NJ
Zip	:	07604-3112
Country	:	US
Telephone Number	:	201-288-4252
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2017
Last Update Date	:	09/18/2017

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