Provider Demographics
NPI:1356641310
Name:JAQUILLARD, JENNIFER (RN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:JAQUILLARD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:288 LAKE AVE S
Mailing Address - Street 2:
Mailing Address - City:NESCONSET
Mailing Address - State:NY
Mailing Address - Zip Code:11767-1879
Mailing Address - Country:US
Mailing Address - Phone:631-739-8885
Mailing Address - Fax:
Practice Address - Street 1:288 LAKE AVE S
Practice Address - Street 2:
Practice Address - City:NESCONSET
Practice Address - State:NY
Practice Address - Zip Code:11767-1879
Practice Address - Country:US
Practice Address - Phone:631-739-8885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY634451-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse