Provider Demographics
NPI:1477312809
Name:DOUGLAS, JERI-SUE
Entity Type:Individual
Prefix:
First Name:JERI-SUE
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 PECONIC AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-3549
Mailing Address - Country:US
Mailing Address - Phone:631-521-3821
Mailing Address - Fax:
Practice Address - Street 1:328 PECONIC AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-3549
Practice Address - Country:US
Practice Address - Phone:631-521-3821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY509726163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse