Provider Demographics
NPI:1720384688
Name:GAINES, JACQUELINE M
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:GAINES
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 1:78 ALBERTA ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14619-1047
Mailing Address - Country:US
Mailing Address - Phone:585-290-5025
Mailing Address - Fax:
Practice Address - Street 1:78 ALBERTA ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14619-1047
Practice Address - Country:US
Practice Address - Phone:585-290-5025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-09
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224987-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse