Provider Demographics
NPI:1528882743
Name:MITRA, JACQUELYN
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:MITRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:
Other - Last Name:KONKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:350 HERB HILL RD APT 217
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-4407
Mailing Address - Country:US
Mailing Address - Phone:347-651-5425
Mailing Address - Fax:
Practice Address - Street 1:299 HALLOCK AVE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1217
Practice Address - Country:US
Practice Address - Phone:631-469-3842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist