Provider Demographics
NPI:1649431412
Name:JACKLEY, KRISTI L (SPEECH PATHOLOGIST)
Entity type:Individual
Prefix:
First Name:KRISTI
Middle Name:L
Last Name:JACKLEY
Suffix:
Gender:F
Credentials:SPEECH PATHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 MOUNT ARGYLL CT
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-4738
Mailing Address - Country:US
Mailing Address - Phone:321-230-1124
Mailing Address - Fax:321-256-5211
Practice Address - Street 1:525 MOUNT ARGYLL CT
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32712-4738
Practice Address - Country:US
Practice Address - Phone:321-230-1124
Practice Address - Fax:321-256-5211
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-24
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL008163235Z00000X
FLSA7750235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003686500Medicaid