Provider Demographics
NPI:1043645161
Name:PORCO, JACLYN SUZANNE
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:SUZANNE
Last Name:PORCO
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 1:17 COUNTRY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:RYE BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:10573-7043
Mailing Address - Country:US
Mailing Address - Phone:619-929-7324
Mailing Address - Fax:
Practice Address - Street 1:5 PERRYRIDGE RD
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-4608
Practice Address - Country:US
Practice Address - Phone:212-746-2959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-09
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY556384163W00000X
CT123873163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse