Provider Demographics
NPI:1669027447
Name:FUENTES, JACQUELINE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:FUENTES
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 1:1731 BEACON ST APT 704
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-5326
Mailing Address - Country:US
Mailing Address - Phone:845-857-4953
Mailing Address - Fax:
Practice Address - Street 1:1731 BEACON ST APT 704
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-5326
Practice Address - Country:US
Practice Address - Phone:845-857-4953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-07
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030372235Z00000X
MA78260235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist