Provider Demographics
NPI:1124872767
Name:EISSA, JACQUELINE B (PHARMACIST)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:B
Last Name:EISSA
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1561 JOHN F KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07305-1721
Mailing Address - Country:US
Mailing Address - Phone:201-332-4668
Mailing Address - Fax:
Practice Address - Street 1:47 E 31ST ST APT 2
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-4706
Practice Address - Country:US
Practice Address - Phone:201-844-5317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI04364600183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist