Provider Demographics
NPI:1396490538
Name:GONCALVES, JACKLYN M
Entity type:Individual
Prefix:
First Name:JACKLYN
Middle Name:M
Last Name:GONCALVES
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 1:70 16TH ST
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-2419
Mailing Address - Country:US
Mailing Address - Phone:516-406-7899
Mailing Address - Fax:
Practice Address - Street 1:70 GRAND AVE
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-4906
Practice Address - Country:US
Practice Address - Phone:516-799-3203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program