Provider Demographics
NPI:1578964680
Name:SPITZER, JACLYN ROSE (FNP-BC)
Entity Type:Individual
Prefix:MISS
First Name:JACLYN
Middle Name:ROSE
Last Name:SPITZER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OSSINING
Mailing Address - State:NY
Mailing Address - Zip Code:10562-4702
Mailing Address - Country:US
Mailing Address - Phone:914-941-1263
Mailing Address - Fax:
Practice Address - Street 1:1 TAMARACK RD
Practice Address - Street 2:
Practice Address - City:PORT CHESTER
Practice Address - State:NY
Practice Address - Zip Code:10573-2407
Practice Address - Country:US
Practice Address - Phone:914-934-5211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-08
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY339288363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04090891Medicaid