Provider Demographics
NPI:1073890778
Name:FISHER, JACKLYN
Entity Type:Individual
Prefix:DR
First Name:JACKLYN
Middle Name:
Last Name:FISHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 E 89TH ST
Mailing Address - Street 2:APT 4J
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-2318
Mailing Address - Country:US
Mailing Address - Phone:914-629-3924
Mailing Address - Fax:
Practice Address - Street 1:141 E 89TH ST
Practice Address - Street 2:APT 4J
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-2318
Practice Address - Country:US
Practice Address - Phone:914-629-3924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-08
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY0567271223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program