Provider Demographics
NPI:1730624289
Name:HERNANDEZ SANCHEZ, JACKELIN
Entity type:Individual
Prefix:
First Name:JACKELIN
Middle Name:
Last Name:HERNANDEZ SANCHEZ
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 1:138 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5850
Mailing Address - Country:US
Mailing Address - Phone:732-930-9574
Mailing Address - Fax:
Practice Address - Street 1:9800 TOUCHTON RD APT 815
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-8291
Practice Address - Country:US
Practice Address - Phone:732-930-9574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-19
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ16-612246ZC0007X
FL11025588363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant