Provider Demographics
NPI:1700949526
Name:DIX, JACQUELYN ESTERDAY (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:ESTERDAY
Last Name:DIX
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:ESTERDAY
Other - Last Name:DIX
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:187 MILLBURN AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041-1847
Mailing Address - Country:US
Mailing Address - Phone:973-379-1441
Mailing Address - Fax:973-379-6120
Practice Address - Street 1:187 MILLBURN AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:MILLBURN
Practice Address - State:NJ
Practice Address - Zip Code:07041-1847
Practice Address - Country:US
Practice Address - Phone:973-379-1441
Practice Address - Fax:973-379-6120
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA35152174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2531402Medicaid
NJ2531402Medicaid
NJC35936Medicare UPIN