Provider Demographics
NPI:1972052199
Name:HEBRANK, JACQUELINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:HEBRANK
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 1:121 PUTNAM DR APT 1
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:NY
Mailing Address - Zip Code:10512-5655
Mailing Address - Country:US
Mailing Address - Phone:845-225-4715
Mailing Address - Fax:
Practice Address - Street 1:777 WESTCHESTER AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10604-3520
Practice Address - Country:US
Practice Address - Phone:914-997-0420
Practice Address - Fax:877-306-1432
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-29
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY258030164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse