Provider Demographics
NPI:1437568086
Name:YSIQUE, JACQUELINE (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:YSIQUE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 10TH ST
Mailing Address - Street 2:
Mailing Address - City:SECAUCUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07094-2921
Mailing Address - Country:US
Mailing Address - Phone:201-865-2050
Mailing Address - Fax:
Practice Address - Street 1:714 10TH ST
Practice Address - Street 2:
Practice Address - City:SECAUCUS
Practice Address - State:NJ
Practice Address - Zip Code:07094-2921
Practice Address - Country:US
Practice Address - Phone:201-865-2050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-07
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09573400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine