Basic Information
| Provider Information | |||||||||
| NPI: | 1346830262 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACILDO | ||||||||
| FirstName: | MARIE GRACE | ||||||||
| MiddleName: | SANCHEZ | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6550 | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136016550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157887430 | ||||||||
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| Practice Location | |||||||||
| Address1: | 211 JB WISE PLAZA | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136011360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157887430 | ||||||||
| FaxNumber: | 3157855637 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2021 | ||||||||
| LastUpdateDate: | 01/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 734882 | NY | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.