Provider Demographics
NPI:1508306390
Name:SOARES, JACQUELINE JESSICA
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:JESSICA
Last Name:SOARES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 CYPRESS LOOP
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-1676
Mailing Address - Country:US
Mailing Address - Phone:646-842-0270
Mailing Address - Fax:
Practice Address - Street 1:51 CYPRESS LOOP
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309-1676
Practice Address - Country:US
Practice Address - Phone:646-842-0270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-28
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00788300235Z00000X
NY024224235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist