Provider Demographics
NPI:1255946174
Name:DOLPHIN, JACLYN
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:DOLPHIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6458 COOPER AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11385-6933
Mailing Address - Country:US
Mailing Address - Phone:646-400-3077
Mailing Address - Fax:
Practice Address - Street 1:1414 NEWKIRK AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-6599
Practice Address - Country:US
Practice Address - Phone:718-576-6822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025214363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant