Provider Demographics
NPI:1962629550
Name:SACKETT, JACQUELYN MARY (SPEECH LANGUAGE PATH)
Entity Type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:MARY
Last Name:SACKETT
Suffix:
Gender:F
Credentials:SPEECH LANGUAGE PATH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 GLENWOOD AVENUE
Mailing Address - Street 2:
Mailing Address - City:SILVER CREEK
Mailing Address - State:NY
Mailing Address - Zip Code:14136
Mailing Address - Country:US
Mailing Address - Phone:716-934-2597
Mailing Address - Fax:
Practice Address - Street 1:87 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SILVER CREEK
Practice Address - State:NY
Practice Address - Zip Code:14136
Practice Address - Country:US
Practice Address - Phone:716-934-4274
Practice Address - Fax:716-934-9129
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007225-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist