Provider Demographics
NPI:1083360655
Name:UPCHURCH, JACLYN (SLP)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:UPCHURCH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7440 HAGUE RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-1930
Mailing Address - Country:US
Mailing Address - Phone:317-863-9278
Mailing Address - Fax:317-534-3215
Practice Address - Street 1:7478 SHADELAND STATION WAY
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-3925
Practice Address - Country:US
Practice Address - Phone:317-762-8449
Practice Address - Fax:317-534-3215
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22008002A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty