Provider Demographics
NPI:1356464606
Name:KNOBLOCH, JACQUELYN B (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:B
Last Name:KNOBLOCH
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 1:31320 BRIDGEGATE DR
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33545-8221
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8583 DYNASTY DR
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-6823
Practice Address - Country:US
Practice Address - Phone:585-797-8937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 9838235Z00000X
NY018660-1235Z00000X
FLSA9838222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000816100Medicaid
FL003772200Medicaid