Provider Demographics
NPI:1336427137
Name:PETERS, JACLYN LYNAE
Entity Type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:LYNAE
Last Name:PETERS
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JACLYN
Other - Middle Name:LYNAE
Other - Last Name:GROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:350 HENRY CLAY BLVD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40502-1024
Mailing Address - Country:US
Mailing Address - Phone:859-268-4545
Mailing Address - Fax:859-269-1857
Practice Address - Street 1:350 HENRY CLAY BLVD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502-1024
Practice Address - Country:US
Practice Address - Phone:859-268-4545
Practice Address - Fax:859-269-1857
Is Sole Proprietor?:No
Enumeration Date:2011-07-27
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4095235Z00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100334640Medicaid