Provider Demographics
NPI:1811964281
Name:GAGEN, JACQUELINE JOY (CNM, FNP)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:JOY
Last Name:GAGEN
Suffix:
Gender:F
Credentials:CNM, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 ALVENA AVE, SUITE 101
Mailing Address - Street 2:OB/GYN ASSOC. OF CORTLAND, MD, PC
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045
Mailing Address - Country:US
Mailing Address - Phone:315-446-3904
Mailing Address - Fax:315-445-2936
Practice Address - Street 1:1 GUTHRIE SQ
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-1625
Practice Address - Country:US
Practice Address - Phone:570-888-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6153461207V00000X, 207VG0400X, 207VX0000X
NY360384363LX0001X
NYF000501367A00000X
NY343016363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP38745Medicare UPIN
P38745Medicare UPIN