Provider Demographics
NPI:1255408589
Name:SHELLUM, JACQUELINE MARIE
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:MARIE
Last Name:SHELLUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3788 GRAEBER AVENUE
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL BEACH
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:L0S 1B0
Mailing Address - Country:CA
Mailing Address - Phone:905-894-8215
Mailing Address - Fax:
Practice Address - Street 1:2565 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1939
Practice Address - Country:US
Practice Address - Phone:716-871-9883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012656-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist