Healthcare Provider Details

I. General information

NPI: 1922624667
Provider Name (Legal Business Name): JACLYN PRISCILLA SLATE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. JACLYN SMITH

II. Dates (important events)

Enumeration Date: 06/18/2020
Last Update Date: 11/14/2025
Certification Date: 11/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 PARK ST
OGDENSBURG NY
13669-3911
US

IV. Provider business mailing address

482 BLACK RIVER PKWY
WATERTOWN NY
13601-2416
US

V. Phone/Fax

Practice location:
  • Phone: 315-713-9090
  • Fax: 315-713-9330
Mailing address:
  • Phone: 315-782-1777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number106707
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number955332
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: