Jacklyn Gannon

Primary specialty

Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X

License

405347 Issued in NY

Practice address

101 Nicolls Rd
Stony Brook, NY 11794-0001

Phone

(631) 638-1036

NPI assigned

Sep 18, 2023

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in NY

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Nurse Practitioner

Education

Other, 2023

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Telehealth

Offers telehealth services

Group practices

Psychiatric Nurse Practitioner PCGroup PAC ID 6901221795, 45 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Psychiatric Nurse Practitioner P.C

  • Psychiatric/Mental Health Nurse Practitioner
  • New York, NY
  • NPI 1518595727
  Medicare reassignment Care Compare group NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1694995200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1696896000000",
    "number": "1841078359",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "55C COMMODORE LN",
            "city": "WEST BABYLON",
            "state": "NY",
            "postal_code": "117048203",
            "telephone_number": "631-560-0970"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "101 NICOLLS RD",
            "city": "STONY BROOK",
            "state": "NY",
            "postal_code": "117940001",
            "telephone_number": "631-638-1036"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "GANNON",
        "first_name": "JACKLYN",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2023-09-18",
        "last_updated": "2023-10-10",
        "certification_date": "2023-10-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "163WE0003X",
            "taxonomy_group": "",
            "desc": "Registered Nurse, Emergency",
            "state": "NY",
            "license": "745153",
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "NY",
            "license": "405347",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Juliette Jean Gammel
• Leah Gancz
• Sandhya Ganesan
• Vanathi Ganesan
• Cheyenne Ganesh, DO
• Manuel Andres Garcia-Smester, MD
• Elizabeth Garcia, RN
• Jessica Garcia
• Mireya Garcia, M.D.
• Victor Garcia

• Psychiatric/Mental Health Nurse Practitioner in Stony Brook, NY
• Providers in Stony Brook, NY by specialty
• Psychiatric/Mental Health Nurse Practitioner in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 10, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.