Provider Demographics
NPI:1184186447
Name:DEROSSO, JACLYN RENEE (AUD)
Entity Type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:RENEE
Last Name:DEROSSO
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:RENEE
Other - Last Name:PAULSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5309 SW MULTNOMAH BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-3345
Mailing Address - Country:US
Mailing Address - Phone:541-979-2344
Mailing Address - Fax:
Practice Address - Street 1:18040 SHERMAN WAY
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-4631
Practice Address - Country:US
Practice Address - Phone:503-997-4669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-04
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR30928231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist