Provider Demographics
NPI:1568725513
Name:CHAMBERLAIN, JACQUELYNE MARIE
Entity Type:Individual
Prefix:MRS
First Name:JACQUELYNE
Middle Name:MARIE
Last Name:CHAMBERLAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELYNE
Other - Middle Name:MARIE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:51 SAINT JOHNS PARKSIDE ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14210-2515
Mailing Address - Country:US
Mailing Address - Phone:716-828-9560
Mailing Address - Fax:716-828-9467
Practice Address - Street 1:51 SAINT JOHNS PARKSIDE ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14210-2515
Practice Address - Country:US
Practice Address - Phone:716-828-9560
Practice Address - Fax:716-828-9467
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-22
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist