Provider Demographics
NPI:1598049686
Name:VASQUEZ, JACQUELINE M (OTA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4604 FORT HAMILTON PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-2413
Mailing Address - Country:US
Mailing Address - Phone:323-428-0993
Mailing Address - Fax:
Practice Address - Street 1:4604 FORT HAMILTON PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2413
Practice Address - Country:US
Practice Address - Phone:323-428-0994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006129-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist