Provider Demographics
NPI:1780861724
Name:LEITNER, JACLYN MELISSA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:MELISSA
Last Name:LEITNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 ADAMS ST
Mailing Address - Street 2:APT 510
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-2631
Mailing Address - Country:US
Mailing Address - Phone:201-491-3449
Mailing Address - Fax:
Practice Address - Street 1:31-00 BROADWAY
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3963
Practice Address - Country:US
Practice Address - Phone:201-796-2255
Practice Address - Fax:201-796-7020
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00188300363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical