Provider Demographics
NPI:1790489110
Name:BIDO, JACQUELEEN MAREEN
Entity Type:Individual
Prefix:
First Name:JACQUELEEN
Middle Name:MAREEN
Last Name:BIDO
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 1:4631 SLOEWOOD CT FL 32757
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-7238
Mailing Address - Country:US
Mailing Address - Phone:407-920-6915
Mailing Address - Fax:
Practice Address - Street 1:331 WOODSIDE AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-4362
Practice Address - Country:US
Practice Address - Phone:407-920-6915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-29
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty