Basic Information
| Provider Information | |||||||||
| NPI: | 1912284316 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SLY | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 LIBERTY ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023015521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088940400 | ||||||||
| FaxNumber: | 5088940356 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 LIBERTY ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088940400 | ||||||||
| FaxNumber: | 5088940356 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2011 | ||||||||
| LastUpdateDate: | 08/21/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SF0001X | RN189769 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Family Health |
No ID Information.