Provider Demographics
NPI:1982821278
Name:JARRELL, DARA (SLP)
Entity Type:Individual
Prefix:
First Name:DARA
Middle Name:
Last Name:JARRELL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:941 WATERFALL DR NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-3711
Mailing Address - Country:US
Mailing Address - Phone:505-256-5142
Mailing Address - Fax:
Practice Address - Street 1:941 WATERFALL DR NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-3711
Practice Address - Country:US
Practice Address - Phone:505-256-5142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3963235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM80389562Medicaid