Provider Demographics
NPI:1023739893
Name:JOHNS, JACQUELINE ALTHEA
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ALTHEA
Last Name:JOHNS
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 1:8 CLEARBROOK DR
Mailing Address - Street 2:
Mailing Address - City:MAHOPAC
Mailing Address - State:NY
Mailing Address - Zip Code:10541-2028
Mailing Address - Country:US
Mailing Address - Phone:347-610-3250
Mailing Address - Fax:
Practice Address - Street 1:8 CLEARBROOK DR
Practice Address - Street 2:
Practice Address - City:MAHOPAC
Practice Address - State:NY
Practice Address - Zip Code:10541-2028
Practice Address - Country:US
Practice Address - Phone:347-610-3250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-08
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY959355163WG0600X, 163WH0200X, 163WG0000X, 163WH1000X, 163WP0200X, 163WR0400X, 163WS0200X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WG0600XNursing Service ProvidersRegistered NurseGerontology
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No163WH1000XNursing Service ProvidersRegistered NurseHospice
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
No163WR0400XNursing Service ProvidersRegistered NurseRehabilitationGroup - Multi-Specialty
No163WS0200XNursing Service ProvidersRegistered NurseSchool