Provider Demographics
NPI:1891959235
Name:POLLARD, JACIE JEAN (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:JACIE
Middle Name:JEAN
Last Name:POLLARD
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-2609
Mailing Address - Country:US
Mailing Address - Phone:208-269-0480
Mailing Address - Fax:
Practice Address - Street 1:1110 CALL CREEK DR
Practice Address - Street 2:SUITE #7
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3072
Practice Address - Country:US
Practice Address - Phone:208-233-4660
Practice Address - Fax:208-233-4262
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-15
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1749235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDSLP-1749OtherSTATE LICENSE #
12130374OtherASHA CERTIFICATION #