Provider Demographics
NPI:1508008251
Name:JACKE, PATTI JEAN (MA)
Entity Type:Individual
Prefix:MS
First Name:PATTI JEAN
Middle Name:
Last Name:JACKE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:PATTI JEAN
Other - Middle Name:
Other - Last Name:JACKE-TERMINELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3014 GLIN CIRCLE
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-2000
Mailing Address - Country:US
Mailing Address - Phone:386-492-7333
Mailing Address - Fax:386-492-7333
Practice Address - Street 1:3014 GLIN CIRCLE
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174
Practice Address - Country:US
Practice Address - Phone:386-492-7333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-26
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000212231H00000X
FLAY1537231H00000X
NY000528-1231H00000X
CT002993235Z00000X
FLSA9828235Z00000X
NY010690-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist