Provider Demographics
NPI:1356126304
Name:MOLLOY, JACLYN MARIE
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:MARIE
Last Name:MOLLOY
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 1:89 LALLY FARM DR
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:MA
Mailing Address - Zip Code:02339-1255
Mailing Address - Country:US
Mailing Address - Phone:781-799-6830
Mailing Address - Fax:
Practice Address - Street 1:89 LALLY FARM DR
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:MA
Practice Address - Zip Code:02339-1255
Practice Address - Country:US
Practice Address - Phone:781-799-6830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2350456163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse