Healthcare Provider Details

I. General information

NPI: 1689012247
Provider Name (Legal Business Name): MS. JACLYN ANN VENDITTO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2013
Last Update Date: 06/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 FERN PL
PLAINVIEW NY
11803-4725
US

IV. Provider business mailing address

4 FERN PL
PLAINVIEW NY
11803-4725
US

V. Phone/Fax

Practice location:
  • Phone: 516-933-4700
  • Fax: 516-653-0110
Mailing address:
  • Phone: 516-933-4700
  • Fax: 516-653-0110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: