Provider Demographics
NPI:1205169315
Name:BOTTENBLEY, JACQUELINE (MSED)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:BOTTENBLEY
Suffix:
Gender:F
Credentials:MSED
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 283
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11582-0283
Mailing Address - Country:US
Mailing Address - Phone:516-561-6522
Mailing Address - Fax:
Practice Address - Street 1:88-66 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:NY
Practice Address - Zip Code:11385
Practice Address - Country:US
Practice Address - Phone:718-850-0400
Practice Address - Fax:718-850-4441
Is Sole Proprietor?:No
Enumeration Date:2009-09-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist