Provider Demographics
NPI:1629531967
Name:BATES, JACALYN NOBIS (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:JACALYN
Middle Name:NOBIS
Last Name:BATES
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 1:9824 SHADY LAKE RD
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NY
Mailing Address - Zip Code:13316-4813
Mailing Address - Country:US
Mailing Address - Phone:315-334-2845
Mailing Address - Fax:
Practice Address - Street 1:16 FRAVOR RD
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:NY
Practice Address - Zip Code:13114-3011
Practice Address - Country:US
Practice Address - Phone:315-963-8400
Practice Address - Fax:315-963-3848
Is Sole Proprietor?:No
Enumeration Date:2019-04-12
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013181235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist