Provider Demographics
NPI:1508472259
Name:VITKOVSKY, JACLYN MARIE
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:MARIE
Last Name:VITKOVSKY
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 1:79 WOODSIDE CT
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06795-1152
Mailing Address - Country:US
Mailing Address - Phone:203-232-5397
Mailing Address - Fax:
Practice Address - Street 1:503 NEW HARWINTON RD
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-5845
Practice Address - Country:US
Practice Address - Phone:914-552-2868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-18
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT107346163W00000X
CT9168363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse