Provider Demographics
NPI:1568790152
Name:DE JACQ, KRYSTYNA (NP)
Entity Type:Individual
Prefix:
First Name:KRYSTYNA
Middle Name:
Last Name:DE JACQ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 PALMER CT APT 2E
Mailing Address - Street 2:
Mailing Address - City:MAMARONECK
Mailing Address - State:NY
Mailing Address - Zip Code:10543-2442
Mailing Address - Country:US
Mailing Address - Phone:917-513-0273
Mailing Address - Fax:
Practice Address - Street 1:709 PALMER CT APT 2E
Practice Address - Street 2:
Practice Address - City:MAMARONECK
Practice Address - State:NY
Practice Address - Zip Code:10543-2442
Practice Address - Country:US
Practice Address - Phone:917-513-0273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-20
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4012382084P0800X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry