Provider Demographics
NPI:1366190829
Name:DAVIS, JACLYN MARIE (MA/CAS)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:MARIE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MA/CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:453 SURREY DR
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-9378
Mailing Address - Country:US
Mailing Address - Phone:607-342-4378
Mailing Address - Fax:
Practice Address - Street 1:9 CENTRAL PARK PLACE
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:NY
Practice Address - Zip Code:13077
Practice Address - Country:US
Practice Address - Phone:607-749-1250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103TS0200X
NY965888151103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool