Provider Demographics
NPI:1689737421
Name:BRECKOW, JACQULYN (SLP)
Entity Type:Individual
Prefix:MRS
First Name:JACQULYN
Middle Name:
Last Name:BRECKOW
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 E WARNER RD
Mailing Address - Street 2:SUITE #105
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-3054
Mailing Address - Country:US
Mailing Address - Phone:480-820-6366
Mailing Address - Fax:480-820-0462
Practice Address - Street 1:690 E WARNER RD
Practice Address - Street 2:SUITE #105
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-3054
Practice Address - Country:US
Practice Address - Phone:480-820-6366
Practice Address - Fax:480-820-0462
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2012-12-18
Deactivation Date:2010-06-18
Deactivation Code:
Reactivation Date:2012-11-02
Provider Licenses
StateLicense IDTaxonomies
AZTSLP4726235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ948317Medicaid