Provider Demographics
NPI:1265779979
Name:SHASHA, JACLYN MARIE (MS)
Entity type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:MARIE
Last Name:SHASHA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40055 TINDERBOX WAY
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562
Mailing Address - Country:US
Mailing Address - Phone:951-660-2961
Mailing Address - Fax:
Practice Address - Street 1:41176 GUAVA ST. SUITE A
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562
Practice Address - Country:US
Practice Address - Phone:951-660-2961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-15
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21834235Z00000X
21834261QH0700X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No174400000XOther Service ProvidersSpecialist