Healthcare Provider Details

I. General information

NPI: 1477802932
Provider Name (Legal Business Name): MS. JACLYN WENZEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2012
Last Update Date: 12/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 E BETHPAGE RD STE 5
PLAINVIEW NY
11803-4228
US

IV. Provider business mailing address

121 OLIVE DR
LYNBROOK NY
11563-2908
US

V. Phone/Fax

Practice location:
  • Phone: 516-731-5588
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNY

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: