Provider Demographics
NPI:1457530404
Name:GINCHEREAU, JAQUELINE E (MD)
Entity Type:Individual
Prefix:
First Name:JAQUELINE
Middle Name:E
Last Name:GINCHEREAU
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 1:174 WEST WATERVIEW ST
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-1241
Mailing Address - Country:US
Mailing Address - Phone:631-757-6698
Mailing Address - Fax:
Practice Address - Street 1:174 WEST WATERVIEW ST
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-1241
Practice Address - Country:US
Practice Address - Phone:631-757-6698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-26
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1174792084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
B12217Medicare UPIN