Provider Demographics
NPI:1609203629
Name:SMITH, JACLYN (CNM)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 CROSS ST
Mailing Address - Street 2:UNIT 202
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901-4622
Mailing Address - Country:US
Mailing Address - Phone:845-596-4788
Mailing Address - Fax:845-357-2495
Practice Address - Street 1:270 OLD HOOK RD
Practice Address - Street 2:
Practice Address - City:WESTWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07675-3117
Practice Address - Country:US
Practice Address - Phone:201-358-0505
Practice Address - Fax:201-358-1515
Is Sole Proprietor?:No
Enumeration Date:2013-10-04
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25ME00054101367A00000X
NJ25ME00054100367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife