Provider Demographics
NPI:1457665820
Name:WAHLQUIST, JORDAN SIMS (MS)
Entity Type:Individual
Prefix:MRS
First Name:JORDAN
Middle Name:SIMS
Last Name:WAHLQUIST
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11899 NW LAKE MYSTIC DUGGAR RD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:FL
Mailing Address - Zip Code:32321-3929
Mailing Address - Country:US
Mailing Address - Phone:850-643-2088
Mailing Address - Fax:
Practice Address - Street 1:11899 NW LAKE MYSTIC DUGGAR RD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:FL
Practice Address - Zip Code:32321-3929
Practice Address - Country:US
Practice Address - Phone:850-643-2088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-28
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist