Provider Demographics
NPI:1558399337
Name:THORESZ, JACLYN (NP)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:THORESZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 E SHORE RD
Mailing Address - Street 2:#112
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11023-2433
Mailing Address - Country:US
Mailing Address - Phone:516-482-7810
Mailing Address - Fax:516-829-6887
Practice Address - Street 1:233 E SHORE RD
Practice Address - Street 2:#112
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11023-2433
Practice Address - Country:US
Practice Address - Phone:516-482-7810
Practice Address - Fax:516-829-6887
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF304224-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ59807Medicare UPIN
NY1433G1Medicare ID - Type Unspecified