Provider Demographics
NPI:1992830087
Name:CLANCY, JONATHAN D (SLP)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:CLANCY
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 SULLIVAN TRL
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18040-7958
Mailing Address - Country:US
Mailing Address - Phone:610-991-2034
Mailing Address - Fax:
Practice Address - Street 1:300 RIVERMEAD RD
Practice Address - Street 2:
Practice Address - City:PETERBOROUGH
Practice Address - State:NH
Practice Address - Zip Code:03458-1762
Practice Address - Country:US
Practice Address - Phone:610-991-2034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH306517Medicare Oscar/Certification