Provider Demographics
NPI:1093304594
Name:JAEKLE, ALLISON OLIVIA
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:OLIVIA
Last Name:JAEKLE
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 1:119 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-1729
Mailing Address - Country:US
Mailing Address - Phone:631-557-3043
Mailing Address - Fax:
Practice Address - Street 1:7901 4TH AVE STE A20
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-3957
Practice Address - Country:US
Practice Address - Phone:718-491-5800
Practice Address - Fax:718-748-2151
Is Sole Proprietor?:No
Enumeration Date:2021-01-11
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00000000000207N00000X
NY026397-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology