Provider Demographics
NPI:1578006052
Name:WATSON, JACLYN MARIE (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:MARIE
Last Name:WATSON
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1980 CROYDON DR
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-2302
Mailing Address - Country:US
Mailing Address - Phone:516-659-3098
Mailing Address - Fax:
Practice Address - Street 1:5637 188TH ST
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-2230
Practice Address - Country:US
Practice Address - Phone:718-357-4650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-01
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023617235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist