Provider Demographics
NPI:1114488434
Name:CASERTA, JACLYN MICHELLE (SLP)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:MICHELLE
Last Name:CASERTA
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 1:2110 MOON STATION DR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-2759
Mailing Address - Country:US
Mailing Address - Phone:627-770-2267
Mailing Address - Fax:
Practice Address - Street 1:2110 MOON STATION DR NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-2759
Practice Address - Country:US
Practice Address - Phone:627-770-2267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP010583235Z00000X
NC13415235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist