Provider Demographics
NPI:1922300391
Name:ANDERSON, JACQUELINE MARIE (MED)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6229 LAWNTON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-2601
Mailing Address - Country:US
Mailing Address - Phone:215-487-2995
Mailing Address - Fax:
Practice Address - Street 1:6229 LAWNTON ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-2601
Practice Address - Country:US
Practice Address - Phone:215-487-2995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL002851L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist