Provider Demographics
NPI:1912396219
Name:BASSO, JACLYN (MS, RN, CPNP)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:BASSO
Suffix:
Gender:F
Credentials:MS, RN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1020
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:NY
Mailing Address - Zip Code:10532-7507
Mailing Address - Country:US
Mailing Address - Phone:888-633-0033
Mailing Address - Fax:914-593-1802
Practice Address - Street 1:19 BRADHURST AVE
Practice Address - Street 2:SUITE 1400
Practice Address - City:HAWTHORNE
Practice Address - State:NY
Practice Address - Zip Code:10532-2140
Practice Address - Country:US
Practice Address - Phone:914-493-7997
Practice Address - Fax:914-594-4022
Is Sole Proprietor?:No
Enumeration Date:2015-01-10
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY382226363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics