Provider Demographics
NPI:1811591589
Name:CHRISTIE, JACQUELINE NICOLE (RN MS PMHNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:NICOLE
Last Name:CHRISTIE
Suffix:
Gender:F
Credentials:RN MS PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:54 ROUTE 23
Mailing Address - Street 2:
Mailing Address - City:CLAVERACK
Mailing Address - State:NY
Mailing Address - Zip Code:12513-5137
Mailing Address - Country:US
Mailing Address - Phone:518-821-8076
Mailing Address - Fax:
Practice Address - Street 1:325 COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534-1902
Practice Address - Country:US
Practice Address - Phone:518-828-9446
Practice Address - Fax:518-828-9450
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY581496-1163W00000X
NY403370363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse