Provider Demographics
NPI:1437696549
Name:CRERAR HERBACH, JACQUELINE (MT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:CRERAR HERBACH
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10440 QUEENS BLVD APT 19W
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-3657
Mailing Address - Country:US
Mailing Address - Phone:917-533-4466
Mailing Address - Fax:
Practice Address - Street 1:211 E 80TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-0531
Practice Address - Country:US
Practice Address - Phone:646-962-8690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003863-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist