Provider Demographics
NPI:1023186954
Name:SELTZER, JACKIE MYLAND (MA CCC)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:MYLAND
Last Name:SELTZER
Suffix:
Gender:F
Credentials:MA CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 OAKDALE PLACE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304
Mailing Address - Country:US
Mailing Address - Phone:303-426-4373
Mailing Address - Fax:303-938-8103
Practice Address - Street 1:9669 N HURON #102
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80260
Practice Address - Country:US
Practice Address - Phone:303-426-4373
Practice Address - Fax:303-938-8103
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COASHA01008126235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist