Provider Demographics
NPI:1508112442
Name:VIRGIL, JACLYN M (MS)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:M
Last Name:VIRGIL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:M
Other - Last Name:LOMBARDI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11967-0428
Mailing Address - Country:US
Mailing Address - Phone:631-327-1850
Mailing Address - Fax:
Practice Address - Street 1:145 WILLIAM FLOYD PKWY
Practice Address - Street 2:
Practice Address - City:SHIRLEY
Practice Address - State:NY
Practice Address - Zip Code:11967-3441
Practice Address - Country:US
Practice Address - Phone:631-327-1850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-30
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305369174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist