Provider Demographics
NPI:1235114752
Name:FERN, JACQUELINE SHERRY (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:SHERRY
Last Name:FERN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 MEDICAL DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1598
Mailing Address - Country:US
Mailing Address - Phone:631-928-1555
Mailing Address - Fax:631-928-1570
Practice Address - Street 1:2 MEDICAL DR
Practice Address - Street 2:SUITE A
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1598
Practice Address - Country:US
Practice Address - Phone:631-928-1555
Practice Address - Fax:631-928-1570
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175358207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY88F262Medicare ID - Type Unspecified
NYE94716Medicare UPIN