Provider Demographics
NPI:1720101256
Name:CONNELLY, JACQUELYN (PHD)
Entity type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 HAMMOND LN
Mailing Address - Street 2:SUITE B
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-2003
Mailing Address - Country:US
Mailing Address - Phone:518-565-3113
Mailing Address - Fax:
Practice Address - Street 1:11 HAMMOND LN
Practice Address - Street 2:SUITE B
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-2003
Practice Address - Country:US
Practice Address - Phone:518-565-3113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008891103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
54296BMedicare ID - Type Unspecified
R506093Medicare UPIN