Provider Demographics
NPI:1841817301
Name:ITZKOWITZ, JACLYN (PA-C)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:ITZKOWITZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 MUNRO AVE
Mailing Address - Street 2:
Mailing Address - City:HAZLET TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:07734-3028
Mailing Address - Country:US
Mailing Address - Phone:732-977-9094
Mailing Address - Fax:
Practice Address - Street 1:525 E 68TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-4870
Practice Address - Country:US
Practice Address - Phone:212-746-0780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-01
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025079207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine