Provider Demographics
NPI:1851498497
Name:DEATCHER, JACQUELIN VICTORIA (NP, CDE)
Entity Type:Individual
Prefix:
First Name:JACQUELIN
Middle Name:VICTORIA
Last Name:DEATCHER
Suffix:
Gender:F
Credentials:NP, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3225B BROADWAY RD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDER
Mailing Address - State:NY
Mailing Address - Zip Code:14005-9760
Mailing Address - Country:US
Mailing Address - Phone:585-547-3849
Mailing Address - Fax:585-547-3351
Practice Address - Street 1:3325 E MAIN STREET RD
Practice Address - Street 2:
Practice Address - City:ATTICA
Practice Address - State:NY
Practice Address - Zip Code:14011-9506
Practice Address - Country:US
Practice Address - Phone:585-547-3849
Practice Address - Fax:585-547-3351
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303405-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health