Provider Demographics
NPI:1669842837
Name:ROELL, JACLYN NICOLE (MA)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:NICOLE
Last Name:ROELL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:364 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45205-2222
Mailing Address - Country:US
Mailing Address - Phone:513-617-2519
Mailing Address - Fax:
Practice Address - Street 1:3750 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-2506
Practice Address - Country:US
Practice Address - Phone:937-499-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOND. 2015218235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist