Provider Demographics
NPI:1073531794
Name:CANTOR, JACQUELINE KAY (APRN)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:KAY
Last Name:CANTOR
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 FARMINGTON AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119
Mailing Address - Country:US
Mailing Address - Phone:860-508-0942
Mailing Address - Fax:
Practice Address - Street 1:805 FARMINGTON AVE
Practice Address - Street 2:2ND FL.
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119
Practice Address - Country:US
Practice Address - Phone:860-508-0942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001910364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004197283Medicaid
890000327Medicare ID - Type Unspecified
S65939Medicare UPIN