Provider Demographics
NPI:1821705476
Name:BLOODGOOD, JACKLIN DEA
Entity Type:Individual
Prefix:
First Name:JACKLIN
Middle Name:DEA
Last Name:BLOODGOOD
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 1:132 CRUISE RD
Mailing Address - Street 2:
Mailing Address - City:MANAHAWKIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08050-1223
Mailing Address - Country:US
Mailing Address - Phone:732-330-4557
Mailing Address - Fax:
Practice Address - Street 1:132 CRUISE RD
Practice Address - Street 2:
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-1223
Practice Address - Country:US
Practice Address - Phone:732-330-4557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS01081900235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist