Provider Demographics
NPI:1306373642
Name:BOBADILLA, JACKELINE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JACKELINE
Middle Name:
Last Name:BOBADILLA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 BAY ST FL 1
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-2510
Mailing Address - Country:US
Mailing Address - Phone:845-654-4881
Mailing Address - Fax:
Practice Address - Street 1:57 BAY ST FL 1
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-2510
Practice Address - Country:US
Practice Address - Phone:844-400-1975
Practice Address - Fax:845-765-9324
Is Sole Proprietor?:No
Enumeration Date:2017-05-17
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020736208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics