Provider Demographics
NPI:1427384197
Name:TAN, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:TAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 MAIN STREET
Mailing Address - Street 2:PO BOX 1081
Mailing Address - City:BELCHERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:01007
Mailing Address - Country:US
Mailing Address - Phone:413-323-0550
Mailing Address - Fax:413-323-0555
Practice Address - Street 1:13 MAIN STREET
Practice Address - Street 2:
Practice Address - City:BELCHERTOWN
Practice Address - State:MA
Practice Address - Zip Code:01007
Practice Address - Country:US
Practice Address - Phone:413-323-0550
Practice Address - Fax:413-323-0555
Is Sole Proprietor?:No
Enumeration Date:2009-10-30
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7821235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist