Provider Demographics
NPI:1447610043
Name:PONTIVEROS, JACQUELINE PASCUAL (RN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:PASCUAL
Last Name:PONTIVEROS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JACQUELINE LOUISE
Other - Middle Name:PASCUAL
Other - Last Name:PONTIVEROS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:22 MARIE PL UNIT 10
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-3402
Mailing Address - Country:US
Mailing Address - Phone:917-680-7258
Mailing Address - Fax:
Practice Address - Street 1:22 MARIE PL UNIT 10
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-3402
Practice Address - Country:US
Practice Address - Phone:917-680-7258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-25
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY624212163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse