Provider Demographics
NPI:1790868149
Name:NOGAN, JACKLYN JOYCE (DC)
Entity type:Individual
Prefix:DR
First Name:JACKLYN
Middle Name:JOYCE
Last Name:NOGAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:25 N BELLMORE RD
Mailing Address - Street 2:#A
Mailing Address - City:LEVITTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11756-1508
Mailing Address - Country:US
Mailing Address - Phone:516-520-0274
Mailing Address - Fax:516-520-1619
Practice Address - Street 1:25 N BELLMORE RD
Practice Address - Street 2:#A
Practice Address - City:LEVITTOWN
Practice Address - State:NY
Practice Address - Zip Code:11756-1508
Practice Address - Country:US
Practice Address - Phone:516-520-0274
Practice Address - Fax:516-520-1619
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX005390-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC05390-2OtherWORKERS COMPENSATION
NY01774198Medicaid
NY01774198Medicaid
NYC05390-2OtherWORKERS COMPENSATION