Provider Demographics
NPI:1659927770
Name:GELIEN, JACOB (MS SLP-CF)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:GELIEN
Suffix:
Gender:M
Credentials:MS SLP-CF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 W UNION HILLS DR APT 1140
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-1734
Mailing Address - Country:US
Mailing Address - Phone:925-759-9514
Mailing Address - Fax:
Practice Address - Street 1:7000 W HAPPY VALLEY RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-3278
Practice Address - Country:US
Practice Address - Phone:623-445-7645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP12023235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist