Provider Demographics
NPI:1811176183
Name:PRESLEY, JACLYN S (PA)
Entity type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:S
Last Name:PRESLEY
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:4857 STATE ROUTE 5
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:13476
Mailing Address - Country:US
Mailing Address - Phone:315-363-9995
Mailing Address - Fax:315-363-9686
Practice Address - Street 1:4857 STATE ROUTE 5
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:NY
Practice Address - Zip Code:13476
Practice Address - Country:US
Practice Address - Phone:315-363-9995
Practice Address - Fax:315-363-9686
Is Sole Proprietor?:No
Enumeration Date:2007-11-02
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY012218363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02948763Medicaid