Provider Demographics
NPI:1851589964
Name:GARRETT, JACQUELINE L (PA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:L
Last Name:GARRETT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 W 95TH ST
Mailing Address - Street 2:APT. 20D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-6721
Mailing Address - Country:US
Mailing Address - Phone:917-412-7148
Mailing Address - Fax:
Practice Address - Street 1:1825 PARK AVE
Practice Address - Street 2:CLINIC 3, EIGHTH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-1641
Practice Address - Country:US
Practice Address - Phone:212-774-3230
Practice Address - Fax:212-987-0484
Is Sole Proprietor?:No
Enumeration Date:2007-10-15
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010186363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical