Provider Demographics
NPI:1346781457
Name:ROULETTE, JACQUELINE MARY
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARY
Last Name:ROULETTE
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 1:8 LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-2190
Mailing Address - Country:US
Mailing Address - Phone:631-224-4442
Mailing Address - Fax:
Practice Address - Street 1:8 LAUREL AVE
Practice Address - Street 2:
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-2190
Practice Address - Country:US
Practice Address - Phone:631-224-4442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020674363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant