Provider Demographics
NPI:1548516461
Name:GAMBINO, JACLYN MARIE (MS)
Entity type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:MARIE
Last Name:GAMBINO
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3635 BERNARD DR
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-1658
Mailing Address - Country:US
Mailing Address - Phone:516-735-4118
Mailing Address - Fax:
Practice Address - Street 1:300 GARDEN CITY PLZ
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-3302
Practice Address - Country:US
Practice Address - Phone:516-747-9030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-29
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1922677174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist