Provider Demographics
NPI:1629371943
Name:VANDERVORT, JACALYN ANN (RN)
Entity Type:Individual
Prefix:
First Name:JACALYN
Middle Name:ANN
Last Name:VANDERVORT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DELHI
Mailing Address - State:NY
Mailing Address - Zip Code:13753-1221
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:99 MAIN ST
Practice Address - Street 2:
Practice Address - City:DELHI
Practice Address - State:NY
Practice Address - Zip Code:13753-1221
Practice Address - Country:US
Practice Address - Phone:607-832-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-08
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY382602-1163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management