Provider Demographics
NPI:1134590078
Name:GERRY, JACLYN ALICE
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:ALICE
Last Name:GERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:ALICE
Other - Last Name:FEDOLFI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, BCBA
Mailing Address - Street 1:40 KENNEDY BLVD UNIT 512
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-5315
Mailing Address - Country:US
Mailing Address - Phone:603-275-5938
Mailing Address - Fax:
Practice Address - Street 1:40 KENNEDY BLVD UNIT 512
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-5315
Practice Address - Country:US
Practice Address - Phone:603-275-5938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst