Provider Demographics
NPI:1982628335
Name:FERNANDEZ, JACQUELINE (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2160
Mailing Address - Street 2:UNION INTERNAL MEDICINE GROUP
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2027 MORRIS AVE
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083
Practice Address - Country:US
Practice Address - Phone:908-810-9147
Practice Address - Fax:908-688-7518
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA058703207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6198805Medicaid
NJ6198805Medicaid
162057CHWMedicare ID - Type Unspecified