Healthcare Provider Details

I. General information

NPI: 1225491483
Provider Name (Legal Business Name): JACLYN JANKOWSKI D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2016
Last Update Date: 06/28/2022
Certification Date: 04/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 GRAND ST DEPARTMENT OF ORTHOPEDIC SURGERY
JERSEY CITY NJ
07302-4238
US

IV. Provider business mailing address

297 PAVONIA AVE APT 1A
JERSEY CITY NJ
07302-1541
US

V. Phone/Fax

Practice location:
  • Phone: 201-521-5934
  • Fax: 201-915-2025
Mailing address:
  • Phone: 508-523-3544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number25MB11067400
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number25MB11067400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: