Provider Demographics
NPI:1881223220
Name:VALLES, JACQUELINE DAILEY (SLP-CCC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:DAILEY
Last Name:VALLES
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:TAYLOR
Other - Last Name:DAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP-CCC
Mailing Address - Street 1:1546 E SUNNYSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-1633
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1546 E SUNNYSIDE AVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-1633
Practice Address - Country:US
Practice Address - Phone:801-583-6187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-07
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10869040-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist