Provider Demographics
NPI:1215507231
Name:MATTY, JACLYN PAIGE
Entity type:Individual
Prefix:MS
First Name:JACLYN
Middle Name:PAIGE
Last Name:MATTY
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 1:60 CHARLES LINDBERGH BLVD
Mailing Address - Street 2:
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11553-3653
Mailing Address - Country:US
Mailing Address - Phone:165-227-8638
Mailing Address - Fax:
Practice Address - Street 1:750 HICKSVILLE RD
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:NY
Practice Address - Zip Code:11783-1328
Practice Address - Country:US
Practice Address - Phone:516-520-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171M00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No174400000XOther Service ProvidersSpecialist