Provider Demographics
NPI:1528772530
Name:NORRIS, JACLYN (RN)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:NORRIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:
Other - Last Name:ROUGHSEDGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22 E LUZERNE AVE
Mailing Address - Street 2:
Mailing Address - City:LARKSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18704-1025
Mailing Address - Country:US
Mailing Address - Phone:570-718-7065
Mailing Address - Fax:
Practice Address - Street 1:1111 E END BLVD
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711-0030
Practice Address - Country:US
Practice Address - Phone:570-824-3521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN612142163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARN612142OtherPENNSYLVANIA STATE BOARD OF NURSING
VA0001297888OtherVIRGINIA STATE BOARD OF NURSING