Provider Demographics
NPI:1093945255
Name:VINCIGUERRA, JACLYN (SP)
Entity Type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:
Last Name:VINCIGUERRA
Suffix:
Gender:F
Credentials:SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-3824
Mailing Address - Country:US
Mailing Address - Phone:716-661-1583
Mailing Address - Fax:
Practice Address - Street 1:50 E NORTH ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1002
Practice Address - Country:US
Practice Address - Phone:716-856-4201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-22
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019286235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00639487Medicaid