Provider Demographics
NPI:1407220312
Name:MCMILLIAN, JAQUAN JALEEL
Entity Type:Individual
Prefix:
First Name:JAQUAN
Middle Name:JALEEL
Last Name:MCMILLIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2384 ATLANTIC AVE
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11233-3402
Mailing Address - Country:US
Mailing Address - Phone:718-272-6025
Mailing Address - Fax:718-922-7416
Practice Address - Street 1:2384 ATLANTIC AVE
Practice Address - Street 2:4TH FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11233-3402
Practice Address - Country:US
Practice Address - Phone:718-272-6025
Practice Address - Fax:718-922-7416
Is Sole Proprietor?:No
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0851641101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01305004Medicaid