Provider Demographics
NPI:1851496251
Name:SLOAN, JACQULYN SUE
Entity Type:Individual
Prefix:MRS
First Name:JACQULYN
Middle Name:SUE
Last Name:SLOAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:JACQULYN
Other - Middle Name:SUE
Other - Last Name:KEENAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:69713 CRESTVIEW LN
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIRSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43950-8313
Mailing Address - Country:US
Mailing Address - Phone:740-695-9479
Mailing Address - Fax:
Practice Address - Street 1:504 HOWARD ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:OH
Practice Address - Zip Code:43912-1126
Practice Address - Country:US
Practice Address - Phone:740-635-1535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2068237700000X
WV690237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0890013Medicaid
OH900OtherHEALTH PLAN OF THE UPPER