Provider Demographics
NPI:1003254657
Name:PALLICKAL, JAISA JOSEPH (MSN ANP)
Entity Type:Individual
Prefix:MRS
First Name:JAISA
Middle Name:JOSEPH
Last Name:PALLICKAL
Suffix:
Gender:F
Credentials:MSN ANP
Other - Prefix:MRS
Other - First Name:ANNAMMA
Other - Middle Name:
Other - Last Name:ZACHARIAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:17 BEST ST
Mailing Address - Street 2:
Mailing Address - City:WESTWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-2701
Mailing Address - Country:US
Mailing Address - Phone:201-358-0349
Mailing Address - Fax:
Practice Address - Street 1:75 BROAD ST
Practice Address - Street 2:0815
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10004-2415
Practice Address - Country:US
Practice Address - Phone:718-391-0611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305563364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health