Provider Demographics
NPI:1083084248
Name:SHLISKY, JACLYN (PSYD)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:SHLISKY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4545 CENTER BLVD APT 518
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11109-5910
Mailing Address - Country:US
Mailing Address - Phone:516-330-6628
Mailing Address - Fax:
Practice Address - Street 1:4545 CENTER BLVD APT 518
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11109-5910
Practice Address - Country:US
Practice Address - Phone:516-330-6628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020127103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist