Provider Demographics
NPI:1033558937
Name:DUSEL, JACLYN (MA, CCC/L-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:
Last Name:DUSEL
Suffix:
Gender:F
Credentials:MA, CCC/L-SLP
Other - Prefix:MRS
Other - First Name:JACLYN
Other - Middle Name:
Other - Last Name:LEWANDOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC/L-SLP
Mailing Address - Street 1:4242 RIDGE LEA ROAD SUITE 2
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226
Mailing Address - Country:US
Mailing Address - Phone:716-819-2400
Mailing Address - Fax:
Practice Address - Street 1:4242 RIDGE LEA ROAD SUITE 2
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226
Practice Address - Country:US
Practice Address - Phone:716-819-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-24
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022871-1235Z00000X
NY235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03662599Medicaid