Provider Demographics
NPI:1558443655
Name:MCCONVILLE, JACQUELYN C (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:C
Last Name:MCCONVILLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E 85TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-3108
Mailing Address - Country:US
Mailing Address - Phone:469-627-3006
Mailing Address - Fax:
Practice Address - Street 1:215 E 85TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-3108
Practice Address - Country:US
Practice Address - Phone:469-627-3006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA07721100207V00000X
NY242396207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology