Provider Demographics
NPI:1134520364
Name:BUNGO, JACKIE (MA/CCC-SLP)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:BUNGO
Suffix:
Gender:F
Credentials:MA/CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3590 STATE ROUTE 59
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-1380
Mailing Address - Country:US
Mailing Address - Phone:330-297-6708
Mailing Address - Fax:
Practice Address - Street 1:3590 STATE ROUTE 59
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-1380
Practice Address - Country:US
Practice Address - Phone:330-297-6708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP6345235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
12033476OtherASHA
SP6345OtherOHIO BOARD OF SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY