Provider Demographics
NPI:1386492502
Name:STEVENSON, JEANIQUA
Entity type:Individual
Prefix:
First Name:JEANIQUA
Middle Name:
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7403 COMMONWEALTH BLVD
Mailing Address - Street 2:
Mailing Address - City:BELLEROSE
Mailing Address - State:NY
Mailing Address - Zip Code:11426-1839
Mailing Address - Country:US
Mailing Address - Phone:718-264-4805
Mailing Address - Fax:
Practice Address - Street 1:7403 COMMONWEALTH BLVD
Practice Address - Street 2:
Practice Address - City:BELLEROSE
Practice Address - State:NY
Practice Address - Zip Code:11426-1839
Practice Address - Country:US
Practice Address - Phone:718-264-4805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-13
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY873746163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health