Provider Demographics
NPI:1689871733
Name:JAGELMAN, KRISTIN LOVEJOY (MED CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:LOVEJOY
Last Name:JAGELMAN
Suffix:
Gender:F
Credentials:MED CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 NE 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-1238
Mailing Address - Country:US
Mailing Address - Phone:954-815-3542
Mailing Address - Fax:
Practice Address - Street 1:1880 E COMMERCIAL BLVD STE 2
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-3747
Practice Address - Country:US
Practice Address - Phone:954-815-3542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA9056222Q00000X
FLSA 9056235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008335100Medicaid