Provider Demographics
NPI:1932802956
Name:BOGDAN, JACLYN MARIE
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:MARIE
Last Name:BOGDAN
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 1:131 STERLING DR
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-7739
Mailing Address - Country:US
Mailing Address - Phone:315-991-0037
Mailing Address - Fax:
Practice Address - Street 1:2626 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-6003
Practice Address - Country:US
Practice Address - Phone:315-724-5344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY11621-01101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor