Provider Demographics
NPI:1407234750
Name:ANDERSON, JACQUELINE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:DOLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:212 DRAKE RD
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-6610
Mailing Address - Country:US
Mailing Address - Phone:732-754-1268
Mailing Address - Fax:
Practice Address - Street 1:707 N BROADWAY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21205-1832
Practice Address - Country:US
Practice Address - Phone:443-923-1872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-07
Last Update Date:2025-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS01054600235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist