Provider Demographics
NPI:1174941173
Name:KOLOSKY, JACLYN MARIE (DO)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:MARIE
Last Name:KOLOSKY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:ALLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02134-4605
Mailing Address - Country:US
Mailing Address - Phone:617-751-5520
Mailing Address - Fax:
Practice Address - Street 1:226 HARVARD AVE
Practice Address - Street 2:
Practice Address - City:ALLSTON
Practice Address - State:MA
Practice Address - Zip Code:02134-4605
Practice Address - Country:US
Practice Address - Phone:617-751-5520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-07
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
MA274835207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty