Provider Demographics
NPI:1689807737
Name:GAVAGAN, JACQUELINE (MS SLP-CCC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:GAVAGAN
Suffix:
Gender:F
Credentials:MS SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:649 39TH STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11232
Mailing Address - Country:US
Mailing Address - Phone:718-972-0880
Mailing Address - Fax:
Practice Address - Street 1:649 39TH STREET
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11232
Practice Address - Country:US
Practice Address - Phone:718-972-0880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-24
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011732-1235Z00000X
NJ41YS00511400235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist