Provider Demographics
NPI:1578183984
Name:KISLOSKI, JACLYN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:KISLOSKI
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 1:1951 MARSHLAND RD
Mailing Address - Street 2:
Mailing Address - City:APALACHIN
Mailing Address - State:NY
Mailing Address - Zip Code:13732-1440
Mailing Address - Country:US
Mailing Address - Phone:607-972-9885
Mailing Address - Fax:
Practice Address - Street 1:1951 MARSHLAND RD
Practice Address - Street 2:
Practice Address - City:APALACHIN
Practice Address - State:NY
Practice Address - Zip Code:13732-1440
Practice Address - Country:US
Practice Address - Phone:607-972-9885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-26
Last Update Date:2020-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY02942701235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist