Provider Demographics
NPI:1528476686
Name:DECUNZO, JACQUELINE (ANP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:DECUNZO
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2399 ROUTE 34 STE 5
Mailing Address - Street 2:
Mailing Address - City:MANASQUAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08736-1500
Mailing Address - Country:US
Mailing Address - Phone:325-285-5337
Mailing Address - Fax:732-528-0360
Practice Address - Street 1:2399 ROUTE 34
Practice Address - Street 2:
Practice Address - City:MANASQUAN
Practice Address - State:NJ
Practice Address - Zip Code:08736-1500
Practice Address - Country:US
Practice Address - Phone:518-761-6961
Practice Address - Fax:518-761-1006
Is Sole Proprietor?:No
Enumeration Date:2014-07-31
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY306928363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health