Provider Demographics
NPI:1659594455
Name:FACCONE, JACQUELINE M (DO)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:FACCONE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:08812
Mailing Address - Country:US
Mailing Address - Phone:732-537-0310
Mailing Address - Fax:
Practice Address - Street 1:63 RIDGE RD
Practice Address - Street 2:
Practice Address - City:GREEN BROOK
Practice Address - State:NJ
Practice Address - Zip Code:08812
Practice Address - Country:US
Practice Address - Phone:732-537-0310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB62797207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7032404Medicaid
NJ7032404Medicaid