Provider Demographics
NPI:1447561030
Name:GOULD, JACQUELINE S (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:S
Last Name:GOULD
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 HAPPY LN
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1304
Mailing Address - Country:US
Mailing Address - Phone:480-907-4547
Mailing Address - Fax:
Practice Address - Street 1:104 HAPPY LN
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1304
Practice Address - Country:US
Practice Address - Phone:480-907-4547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019622-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist