Provider Demographics
NPI:1013555812
Name:JOHNSON, JACLYN ANNE
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:ANNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:ANNE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:370 CEDAR VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603
Mailing Address - Country:US
Mailing Address - Phone:845-625-4567
Mailing Address - Fax:
Practice Address - Street 1:370 CEDAR VALLEY RD
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603
Practice Address - Country:US
Practice Address - Phone:845-625-4567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY322960164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY322960Medicaid