Provider Demographics
NPI:1063712263
Name:DERISSAINT, JEAN (LPN)
Entity type:Individual
Prefix:MR
First Name:JEAN
Middle Name:
Last Name:DERISSAINT
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:697 E 39TH ST
Mailing Address - Street 2:PH
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-5615
Mailing Address - Country:US
Mailing Address - Phone:718-664-5793
Mailing Address - Fax:
Practice Address - Street 1:697 E 39TH ST
Practice Address - Street 2:PH
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-5615
Practice Address - Country:US
Practice Address - Phone:718-664-5793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-22
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302111-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse