Provider Demographics
NPI:1700587425
Name:LANCIOTTI, JACQUELYN ROSE
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:ROSE
Last Name:LANCIOTTI
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 1:30 PRINCETON ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-4006
Mailing Address - Country:US
Mailing Address - Phone:516-508-0744
Mailing Address - Fax:
Practice Address - Street 1:30 PRINCETON ST
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-4006
Practice Address - Country:US
Practice Address - Phone:516-508-0744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-10
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCJL063W10625OtherEMPIRE BLUE CROSS BLUE SHIELD