Provider Demographics
NPI:1033390653
Name:SULLIVAN, JACQUELINE P (MA,CCC/SLP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:P
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MA,CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:939 W 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-8517
Mailing Address - Country:US
Mailing Address - Phone:407-257-0625
Mailing Address - Fax:407-876-3466
Practice Address - Street 1:1400 S ORLANDO AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-5543
Practice Address - Country:US
Practice Address - Phone:407-257-0625
Practice Address - Fax:407-876-3466
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-26
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA313235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist