Provider Demographics
NPI:1649527599
Name:CHEATHEM, JACQUEL (CCC-SLP)
Entity type:Individual
Prefix:
First Name:JACQUEL
Middle Name:
Last Name:CHEATHEM
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12890 OLD MERIDIAN ST APT 148
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-8899
Mailing Address - Country:US
Mailing Address - Phone:219-201-2785
Mailing Address - Fax:
Practice Address - Street 1:12890 OLD MERIDIAN ST APT 148
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-8899
Practice Address - Country:US
Practice Address - Phone:317-660-5127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-10
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1666235Z00000X
VA2202006802235Z00000X
CA26515235Z00000X
IN22005866A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist