Provider Demographics
NPI:1609419233
Name:JACK, STEPHANIE (MS CCC-SLP/L)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:JACK
Suffix:
Gender:F
Credentials:MS CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20397 ROUTE 19 STE 30
Mailing Address - Street 2:
Mailing Address - City:CRANBERRY TWP
Mailing Address - State:PA
Mailing Address - Zip Code:16066-6102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20397 ROUTE 19 STE 30
Practice Address - Street 2:
Practice Address - City:CRANBERRY TWP
Practice Address - State:PA
Practice Address - Zip Code:16066-6102
Practice Address - Country:US
Practice Address - Phone:855-887-7332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-27
Last Update Date:2019-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL012084235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist