Provider Demographics
NPI:1316675531
Name:IANNACONE, JACQUELINE MARIE (PMHNP-BC, CARN)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:MARIE
Last Name:IANNACONE
Suffix:
Gender:F
Credentials:PMHNP-BC, CARN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:382 ATLANTIS AVE
Mailing Address - Street 2:
Mailing Address - City:MANAHAWKIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08050-2068
Mailing Address - Country:US
Mailing Address - Phone:347-302-3514
Mailing Address - Fax:
Practice Address - Street 1:2640 HIGHWAY 70 BLDG 7A
Practice Address - Street 2:
Practice Address - City:MANASQUAN
Practice Address - State:NJ
Practice Address - Zip Code:08736-2609
Practice Address - Country:US
Practice Address - Phone:347-302-3514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-15
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01352900363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ26NJ01352900OtherADVANCED PRACTICE NURSE - RESIDENT