Provider Demographics
NPI:1710190764
Name:CARR, JACQUELINE M
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:CARR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3220 SOUTH HIGUERA STREET
Mailing Address - Street 2:STE. 320
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6987
Mailing Address - Country:US
Mailing Address - Phone:805-541-1790
Mailing Address - Fax:805-541-1793
Practice Address - Street 1:3220 SOUTH HIGUERA STREET
Practice Address - Street 2:SUITE 320
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-6987
Practice Address - Country:US
Practice Address - Phone:805-541-1790
Practice Address - Fax:805-541-1793
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA 4180237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHA 4180OtherDISPENSER LICENSE