Provider Demographics
NPI:1487183414
Name:BRUSH, JACLYN MARIE (SLP)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:MARIE
Last Name:BRUSH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 INDIAN RUN TRL
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02917-2134
Mailing Address - Country:US
Mailing Address - Phone:860-608-0061
Mailing Address - Fax:
Practice Address - Street 1:7 SMITH AVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:RI
Practice Address - Zip Code:02828-1763
Practice Address - Country:US
Practice Address - Phone:401-954-6040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-04
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA76502235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist