Provider Demographics
NPI:1508250879
Name:EHLIS, JACQUELINE KELLY (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:KELLY
Last Name:EHLIS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7855 TRAPPE RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21222-2347
Mailing Address - Country:US
Mailing Address - Phone:443-809-7038
Mailing Address - Fax:
Practice Address - Street 1:7855 TRAPPE RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21222-2347
Practice Address - Country:US
Practice Address - Phone:443-809-7038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-25
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06377235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1508250879Medicaid