Provider Demographics
NPI:1114384773
Name:DEMATTIA, JACLYN (MS)
Entity Type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:
Last Name:DEMATTIA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 BLUE POINT AVE
Mailing Address - Street 2:
Mailing Address - City:BLUE POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11715-1261
Mailing Address - Country:US
Mailing Address - Phone:631-363-5794
Mailing Address - Fax:
Practice Address - Street 1:235 BLUE POINT AVE
Practice Address - Street 2:
Practice Address - City:BLUE POINT
Practice Address - State:NY
Practice Address - Zip Code:11715-1261
Practice Address - Country:US
Practice Address - Phone:631-363-5794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025368-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist