Provider Demographics
NPI:1114067774
Name:POWELL, JACQUELINE NICOLE (MA CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:JACQUELINE
Middle Name:NICOLE
Last Name:POWELL
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 1:12014 ROYAL CASTLE CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-3184
Mailing Address - Country:US
Mailing Address - Phone:704-516-3110
Mailing Address - Fax:704-341-6078
Practice Address - Street 1:12014 ROYAL CASTLE CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3184
Practice Address - Country:US
Practice Address - Phone:704-516-3110
Practice Address - Fax:704-341-6078
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4913235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7412103Medicaid