Healthcare Provider Details

I. General information

NPI: 1265631501
Provider Name (Legal Business Name): JACLYN ELIZABETH REZNIK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 11/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE # DESKA10
CLEVELAND OH
44195-0001
US

IV. Provider business mailing address

9500 EUCLID AVE # DESKA10
CLEVELAND OH
44195-0001
US

V. Phone/Fax

Practice location:
  • Phone: 216-444-6293
  • Fax:
Mailing address:
  • Phone: 216-444-6293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.002631
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: