Provider Demographics
NPI:1326786559
Name:FLETCHER, JACKIE (AUD)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:FLETCHER
Suffix:
Gender:F
Credentials:AUD
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 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:1225 E COOLSPRING AVE STE 300
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-6312
Practice Address - Country:US
Practice Address - Phone:219-873-2992
Practice Address - Fax:219-878-5052
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-26
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
231H00000X
IN23002798A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty