Individual
JACKLYN GANNON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
101 NICOLLS RD, STONY BROOK, NY 11794-0001
(631) 638-1036
Mailing address
55C COMMODORE LN, WEST BABYLON, NY 11704-8203
(631) 560-0970
Taxonomy
Speciality
Code
Description
License number
State
163WE0003X
Emergency Registered Nurse
745153
NY
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
405347
NY
Other
Enumeration date
09/18/2023
Last updated
10/10/2023
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