Provider Demographics
NPI:1730518622
Name:REGIST, JACQUELINE AUDREY
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:AUDREY
Last Name:REGIST
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:PO BOX 100366
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-0366
Mailing Address - Country:US
Mailing Address - Phone:917-783-0105
Mailing Address - Fax:718-284-0594
Practice Address - Street 1:8866 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:NY
Practice Address - Zip Code:11385-7857
Practice Address - Country:US
Practice Address - Phone:718-850-0400
Practice Address - Fax:718-850-1790
Is Sole Proprietor?:No
Enumeration Date:2013-11-01
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
NY214350174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst