Provider Demographics
NPI:1962595264
Name:SANTORO, JACQUELINE MARIE (PHD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIE
Last Name:SANTORO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 26
Mailing Address - Street 2:
Mailing Address - City:WHITESBORO
Mailing Address - State:NY
Mailing Address - Zip Code:13492-1035
Mailing Address - Country:US
Mailing Address - Phone:315-768-6389
Mailing Address - Fax:315-768-6392
Practice Address - Street 1:10 MAIN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:WHITESBORO
Practice Address - State:NY
Practice Address - Zip Code:13492
Practice Address - Country:US
Practice Address - Phone:315-768-6389
Practice Address - Fax:315-768-6392
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012424103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY56781BMedicare ID - Type Unspecified
S08483Medicare UPIN