Provider Demographics
NPI:1629848627
Name:MENDOZA, JACKELINE ANN
Entity Type:Individual
Prefix:
First Name:JACKELINE
Middle Name:ANN
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16534 NW 89TH PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33018-6172
Mailing Address - Country:US
Mailing Address - Phone:786-382-5274
Mailing Address - Fax:
Practice Address - Street 1:16534 NW 89TH PL
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33018-6172
Practice Address - Country:US
Practice Address - Phone:786-382-5274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6348235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist