Provider Demographics
NPI:1972670636
Name:PROCTOR, JACLIN K (MA, CCC-A)
Entity Type:Individual
Prefix:
First Name:JACLIN
Middle Name:K
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:MA, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 E 86TH AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6381
Mailing Address - Country:US
Mailing Address - Phone:219-738-2528
Mailing Address - Fax:219-756-7825
Practice Address - Street 1:99 E 86TH AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6381
Practice Address - Country:US
Practice Address - Phone:219-738-2528
Practice Address - Fax:219-756-7825
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23000412A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100466390AMedicaid