Healthcare Provider Details

I. General information

NPI: 1861168411
Provider Name (Legal Business Name): JACLYN KRISTIN SHEA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2021
Last Update Date: 03/10/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1723 N OCEAN AVE
MEDFORD NY
11763-2687
US

IV. Provider business mailing address

7 CORKY CT
BLUE POINT NY
11715-1108
US

V. Phone/Fax

Practice location:
  • Phone: 631-758-5858
  • Fax:
Mailing address:
  • Phone: 631-707-5722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number348300
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: