Provider Demographics
NPI:1346017928
Name:SPACE, JACALYN D
Entity Type:Individual
Prefix:
First Name:JACALYN
Middle Name:D
Last Name:SPACE
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:PO BOX 390
Mailing Address - Street 2:
Mailing Address - City:WESTBROOKVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12785-0390
Mailing Address - Country:US
Mailing Address - Phone:845-224-7684
Mailing Address - Fax:
Practice Address - Street 1:5 TRIANGLE RD
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754-3368
Practice Address - Country:US
Practice Address - Phone:845-747-2580
Practice Address - Fax:845-292-0121
Is Sole Proprietor?:No
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator