Provider Demographics
NPI:1790206316
Name:CONKLIN, JESSICA LYNN (LPN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:CONKLIN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 WILLI HILL RD
Mailing Address - Street 2:
Mailing Address - City:SWAN LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12783-5818
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:445 WILLI HILL RD
Practice Address - Street 2:
Practice Address - City:SWAN LAKE
Practice Address - State:NY
Practice Address - Zip Code:12783-5818
Practice Address - Country:US
Practice Address - Phone:845-807-6313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-05
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY306482164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse