Provider Demographics
NPI:1437676178
Name:ROSENBLUM, JACLYN HEATHER
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:HEATHER
Last Name:ROSENBLUM
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 1:2 EDGEWOOD GATE
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-3116
Mailing Address - Country:US
Mailing Address - Phone:516-457-7612
Mailing Address - Fax:
Practice Address - Street 1:2 EDGEWOOD GATE
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803
Practice Address - Country:US
Practice Address - Phone:516-457-7612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1039499161235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist