Provider Demographics
NPI:1497945018
Name:PARRIS, JACQUELINE B (RN, BSN)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:B
Last Name:PARRIS
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 TIMBERLINE DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-6816
Mailing Address - Country:US
Mailing Address - Phone:631-357-3184
Mailing Address - Fax:
Practice Address - Street 1:10 HOLIDAY PARK DR
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-2111
Practice Address - Country:US
Practice Address - Phone:631-656-6813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY458301-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02141046Medicaid