Provider Demographics
NPI:1689816340
Name:FALLON, JACLYN
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:FALLON
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 1:22 SAW MILL RIVER RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:HAWTHORNE
Mailing Address - State:NY
Mailing Address - Zip Code:10532-1533
Mailing Address - Country:US
Mailing Address - Phone:845-947-1772
Mailing Address - Fax:845-947-4487
Practice Address - Street 1:171 RAMAPO RD
Practice Address - Street 2:
Practice Address - City:GARNERVILLE
Practice Address - State:NY
Practice Address - Zip Code:10923-1552
Practice Address - Country:US
Practice Address - Phone:845-947-1772
Practice Address - Fax:845-947-4487
Is Sole Proprietor?:No
Enumeration Date:2009-03-27
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY264124208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03464413Medicaid