Provider Demographics
NPI:1376852582
Name:VAN DER JAGT, ROSEMARIE B (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ROSEMARIE
Middle Name:B
Last Name:VAN DER JAGT
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 1:20 SAXONY RD
Mailing Address - Street 2:
Mailing Address - City:PITTSFORD
Mailing Address - State:NY
Mailing Address - Zip Code:14534-3050
Mailing Address - Country:US
Mailing Address - Phone:585-727-6923
Mailing Address - Fax:
Practice Address - Street 1:2120 BENTON DR
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96003-2151
Practice Address - Country:US
Practice Address - Phone:530-243-6317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-05
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18563235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist