Provider Demographics
NPI:1376897587
Name:MCCULLOCH, JACQUELINE (RN)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:MCCULLOCH
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 1:6321 NEW UTRECHT AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-5425
Mailing Address - Country:US
Mailing Address - Phone:718-388-4100
Mailing Address - Fax:718-388-4236
Practice Address - Street 1:6321 NEW UTRECHT AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-5425
Practice Address - Country:US
Practice Address - Phone:718-388-4100
Practice Address - Fax:718-388-4236
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-09
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY391106163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse