Provider Demographics
NPI:1679224026
Name:PALLAS, JACKLYN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:
Last Name:PALLAS
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 1:318 DAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:MANORVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11949-2011
Mailing Address - Country:US
Mailing Address - Phone:631-275-5013
Mailing Address - Fax:
Practice Address - Street 1:318 DAYTON AVE
Practice Address - Street 2:
Practice Address - City:MANORVILLE
Practice Address - State:NY
Practice Address - Zip Code:11949-2011
Practice Address - Country:US
Practice Address - Phone:631-275-5013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-17
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033072235Z00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist