Provider Demographics
NPI:1083160170
Name:SHALL-MCCUMISKEY, JACQUELINE (PSY D)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:SHALL-MCCUMISKEY
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-2317
Mailing Address - Country:US
Mailing Address - Phone:646-479-8068
Mailing Address - Fax:
Practice Address - Street 1:525 ROUTE 73 N STE 104
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-3422
Practice Address - Country:US
Practice Address - Phone:646-479-8068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021797103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical