Provider Demographics
NPI:1861869703
Name:NGALAME, JACKLINE B (PMHNP)
Entity type:Individual
Prefix:DR
First Name:JACKLINE
Middle Name:B
Last Name:NGALAME
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:DR
Other - First Name:JACKLINE
Other - Middle Name:B
Other - Last Name:TABE -AYUK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4 COMMERCE LN
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-3739
Mailing Address - Country:US
Mailing Address - Phone:315-386-8191
Mailing Address - Fax:315-386-1410
Practice Address - Street 1:4 COMMERCE LN
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-3739
Practice Address - Country:US
Practice Address - Phone:315-386-8191
Practice Address - Fax:315-386-1410
Is Sole Proprietor?:No
Enumeration Date:2015-08-26
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN212748363LF0000X, 363LP0808X
NY402559363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily