Provider Demographics
NPI:1003068958
Name:GOULD, JACQUELINE AVA
Entity Type:Individual
Prefix:MR
First Name:JACQUELINE
Middle Name:AVA
Last Name:GOULD
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 1:121 CREST DR
Mailing Address - Street 2:
Mailing Address - City:TARRYTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10591-4307
Mailing Address - Country:US
Mailing Address - Phone:914-631-1185
Mailing Address - Fax:
Practice Address - Street 1:121 CREST DR
Practice Address - Street 2:
Practice Address - City:TARRYTOWN
Practice Address - State:NY
Practice Address - Zip Code:10591-4307
Practice Address - Country:US
Practice Address - Phone:914-631-1185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0059001235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist