Provider Demographics
NPI:1811194335
Name:MACK, JOALYN DAWN (MACCC SLP)
Entity Type:Individual
Prefix:
First Name:JOALYN
Middle Name:DAWN
Last Name:MACK
Suffix:
Gender:F
Credentials:MACCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11632 E ASBURY PL
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-1102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:940 FILLMORE ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-3852
Practice Address - Country:US
Practice Address - Phone:303-399-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0242153235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO002892552Medicaid