Provider Demographics
NPI:1114202678
Name:MASON, JACQUELYN (RN)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:
Last Name:MASON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-6636
Mailing Address - Country:US
Mailing Address - Phone:631-968-1166
Mailing Address - Fax:631-968-2581
Practice Address - Street 1:155 3RD AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-6636
Practice Address - Country:US
Practice Address - Phone:631-968-1166
Practice Address - Fax:631-968-2581
Is Sole Proprietor?:No
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY406775-1163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool