Provider Demographics
NPI:1629326913
Name:JOHNSON, JACQUELINE J (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-4707
Mailing Address - Country:US
Mailing Address - Phone:605-782-2368
Mailing Address - Fax:605-782-2401
Practice Address - Street 1:1020 W 18TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-4707
Practice Address - Country:US
Practice Address - Phone:605-782-2368
Practice Address - Fax:605-782-2401
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-17
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD12008996235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist