Provider Demographics
NPI:1205224847
Name:MULLET, JACQUELINE (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MULLET
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:PO BOX 182
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:OH
Mailing Address - Zip Code:44610-0182
Mailing Address - Country:US
Mailing Address - Phone:330-893-2610
Mailing Address - Fax:
Practice Address - Street 1:6108 COUNTY ROAD 77
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:OH
Practice Address - Zip Code:44610
Practice Address - Country:US
Practice Address - Phone:330-893-2610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.9854235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist