Provider Demographics
NPI:1487101226
Name:JACQUELINE PONTICIELLO PSYCHIATRIC NP, PLLC
Entity type:Organization
Organization Name:JACQUELINE PONTICIELLO PSYCHIATRIC NP, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:PONTICIELLO
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:607-341-4950
Mailing Address - Street 1:1901 VESTAL PKWY E STE 2W
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-1966
Mailing Address - Country:US
Mailing Address - Phone:607-341-4950
Mailing Address - Fax:607-341-4933
Practice Address - Street 1:1901 VESTAL PKWY E STE 2W
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-1966
Practice Address - Country:US
Practice Address - Phone:607-341-4950
Practice Address - Fax:607-341-4933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-09
Last Update Date:2024-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty