Provider Demographics
NPI:1699395426
Name:DWYER, JACKLYN
Entity type:Individual
Prefix:
First Name:JACKLYN
Middle Name:
Last Name:DWYER
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 1:2598 LOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32254-3211
Mailing Address - Country:US
Mailing Address - Phone:914-620-5279
Mailing Address - Fax:
Practice Address - Street 1:22 OVAL
Practice Address - Street 2:SUITE 100
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12903
Practice Address - Country:US
Practice Address - Phone:518-563-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-22
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104638104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker