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General NPI Number Information
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NPI Number | 1508472259
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Entity Type | Individual
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Provider Name | JACLYN MARIE VITKOVSKY
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Gender | Female
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Dates
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Enumeration Date | 09/18/2020
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Last Update Date | 11/03/2020
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Provider Practice Location Address
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Address Line | 503 NEW HARWINTON RD
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City | TORRINGTON
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State | CT
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Zip | 06790-5845
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Country | US
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Telephone | 914-552-2868
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Fax |
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Provider Business Mailing Address
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Address Line | 79 WOODSIDE CT
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City | WATERTOWN
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State | CT
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Zip | 06795-1152
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Country | US
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Telephone | 203-232-5397
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 9168
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 107346
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License Number State | CT
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