Provider Demographics
NPI:1891164653
Name:BRETOUS, JAQULINE
Entity type:Individual
Prefix:
First Name:JAQULINE
Middle Name:
Last Name:BRETOUS
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 1:512 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-3424
Mailing Address - Country:US
Mailing Address - Phone:516-385-4066
Mailing Address - Fax:
Practice Address - Street 1:512 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-3424
Practice Address - Country:US
Practice Address - Phone:516-385-4066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-22
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY292409164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse