Provider Demographics
NPI:1295367613
Name:COMELLO, JACQUELINE ANN
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN
Last Name:COMELLO
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 1:5586 WOODCREST AVE LOT 2
Mailing Address - Street 2:
Mailing Address - City:FREDONIA
Mailing Address - State:NY
Mailing Address - Zip Code:14063-1539
Mailing Address - Country:US
Mailing Address - Phone:716-951-0763
Mailing Address - Fax:
Practice Address - Street 1:1439 BUFFALO ST
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-1140
Practice Address - Country:US
Practice Address - Phone:716-375-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
P103851101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health