Provider Demographics
NPI:1083750178
Name:DAVIS, JACQUELINE D (MED CCCSLP)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:D
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MED CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 WOODCREST CIR
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-3034
Mailing Address - Country:US
Mailing Address - Phone:478-929-0513
Mailing Address - Fax:478-929-0513
Practice Address - Street 1:134 WOODCREST CIR
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-3034
Practice Address - Country:US
Practice Address - Phone:478-929-0513
Practice Address - Fax:478-929-0513
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP001725235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00661746CMedicaid