Provider Demographics
NPI:1639672397
Name:BERNARD, JACKEE MICHELLE
Entity Type:Individual
Prefix:
First Name:JACKEE
Middle Name:MICHELLE
Last Name:BERNARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4610 61ST ST
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-5766
Mailing Address - Country:US
Mailing Address - Phone:718-791-9490
Mailing Address - Fax:
Practice Address - Street 1:4610 61ST ST
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-5766
Practice Address - Country:US
Practice Address - Phone:718-791-9490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-08
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency