Provider Demographics
NPI:1154511954
Name:JACQUEMAIN, JO ANN (ANP-C)
Entity Type:Individual
Prefix:
First Name:JO ANN
Middle Name:
Last Name:JACQUEMAIN
Suffix:
Gender:F
Credentials:ANP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 WOODLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-1119
Mailing Address - Country:US
Mailing Address - Phone:631-274-5486
Mailing Address - Fax:
Practice Address - Street 1:50 ROUTE 25A
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-1348
Practice Address - Country:US
Practice Address - Phone:631-862-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-27
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF-303899-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health