Provider Demographics
NPI:1225453715
Name:DONGMO MEKONTCHOU, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:DONGMO MEKONTCHOU
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 1:225EAST 149TH STREET
Mailing Address - Street 2:APT. 17G
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451
Mailing Address - Country:US
Mailing Address - Phone:347-898-0813
Mailing Address - Fax:
Practice Address - Street 1:800 CROSS RIVER RD
Practice Address - Street 2:
Practice Address - City:KATONAH
Practice Address - State:NY
Practice Address - Zip Code:10536-3549
Practice Address - Country:US
Practice Address - Phone:347-898-0813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-20
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF403298363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner