Provider Demographics
NPI:1629202783
Name:SISSKIND, JACLYN (MD)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:SISSKIND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7565 NORTHFIELD LN
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-2312
Mailing Address - Country:US
Mailing Address - Phone:315-692-4921
Mailing Address - Fax:
Practice Address - Street 1:8138 OSWEGO RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-1500
Practice Address - Country:US
Practice Address - Phone:315-652-8800
Practice Address - Fax:315-652-8808
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-05
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY264529208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03495585Medicaid