Provider Demographics
NPI:1053458612
Name:JACQUELINE HARTMAN INC
Entity Type:Organization
Organization Name:JACQUELINE HARTMAN INC
Other - Org Name:ELLISVILLE HEARING CENTER AND HEARING CENTER OF KIRKWOOD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:HARTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MA,CCC
Authorized Official - Phone:636-394-4240
Mailing Address - Street 1:15991 MANCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2140
Mailing Address - Country:US
Mailing Address - Phone:636-394-4240
Mailing Address - Fax:
Practice Address - Street 1:15991 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011-2140
Practice Address - Country:US
Practice Address - Phone:636-394-4240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO536231H00000X, 231HA2400X, 231HA2500X, 235Z00000X, 237600000X
MO624237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology PractitionerGroup - Multi-Specialty
No231HA2500XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology SupplierGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO337894109Medicaid