Provider Demographics
NPI:1003384371
Name:LOIACONO, JACQUELINE ROSE
Entity Type:Individual
Prefix:MISS
First Name:JACQUELINE
Middle Name:ROSE
Last Name:LOIACONO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15737 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-1317
Mailing Address - Country:US
Mailing Address - Phone:917-497-3046
Mailing Address - Fax:
Practice Address - Street 1:15737 9TH AVE
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-1317
Practice Address - Country:US
Practice Address - Phone:917-497-3046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1260529174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1260529OtherNYSDOH