Provider Demographics
NPI:1649926395
Name:BREESE, JACQUELINE (PA-C)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BREESE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:959 PANORAMA TRL S STE 100
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14625-2382
Mailing Address - Country:US
Mailing Address - Phone:585-276-9361
Mailing Address - Fax:
Practice Address - Street 1:959 PANORAMA TRL S STE 100
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14625-2382
Practice Address - Country:US
Practice Address - Phone:585-276-9361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-22
Last Update Date:2023-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY29275207R00000X
NY029275363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine