=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043645161
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACLYN SUZANNE PORCO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2013
-----------------------------------------------------
Last Update Date | 04/30/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5 PERRYRIDGE RD
-----------------------------------------------------
City | GREENWICH
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06830-4608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-746-2959
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17 COUNTRY RIDGE DR
-----------------------------------------------------
City | RYE BROOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10573-7043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-929-7324
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 556384
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 123873
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------