Provider Demographics
NPI:1477132538
Name:QUACKENBUSH, JAMES MICHAEL (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:MICHAEL
Last Name:QUACKENBUSH
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 HOLLIS ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03101-1235
Mailing Address - Country:US
Mailing Address - Phone:603-626-9500
Mailing Address - Fax:603-626-9523
Practice Address - Street 1:145 HOLLIS ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03101-1235
Practice Address - Country:US
Practice Address - Phone:603-626-9500
Practice Address - Fax:603-935-9523
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-06
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2303975163W00000X, 363LP0808X
NH073337-23363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse