Provider Demographics
NPI:1841619913
Name:BANNISTER, JACLYN ELENA (MS SP ED)
Entity Type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:ELENA
Last Name:BANNISTER
Suffix:
Gender:F
Credentials:MS SP ED
Other - Prefix:MISS
Other - First Name:JACLYN
Other - Middle Name:ELENA
Other - Last Name:TORRES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS SP ED
Mailing Address - Street 1:3055 71ST ST
Mailing Address - Street 2:#1
Mailing Address - City:EAST ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11370-1412
Mailing Address - Country:US
Mailing Address - Phone:347-556-4013
Mailing Address - Fax:
Practice Address - Street 1:3055 71ST ST
Practice Address - Street 2:#1
Practice Address - City:EAST ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11370-1412
Practice Address - Country:US
Practice Address - Phone:347-556-4013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY445735171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor