Provider Demographics
NPI:1568695807
Name:CHURCHILL, JACLYN NICOLE
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:NICOLE
Last Name:CHURCHILL
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 1:200 W 58TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-1476
Mailing Address - Country:US
Mailing Address - Phone:212-757-7010
Mailing Address - Fax:212-307-0759
Practice Address - Street 1:200 W 58TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1476
Practice Address - Country:US
Practice Address - Phone:212-757-7010
Practice Address - Fax:212-307-0759
Is Sole Proprietor?:No
Enumeration Date:2009-09-03
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9104938363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant