Provider Demographics
NPI:1194443796
Name:TITTL, JACQUELINE MARIE (NP)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:MARIE
Last Name:TITTL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:JACQUELINE
Other - Middle Name:MARIE
Other - Last Name:REA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2001 MARCUS AVE STE W290
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1098
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2001 MARCUS AVE STE W290
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1098
Practice Address - Country:US
Practice Address - Phone:516-238-9282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-19
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY350152363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily