Provider Demographics
NPI:1669514246
Name:JACIR, EDITH LISBETH (CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:EDITH
Middle Name:LISBETH
Last Name:JACIR
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 1:4474 WESTON RD STE 214
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33331-3195
Mailing Address - Country:US
Mailing Address - Phone:954-644-2645
Mailing Address - Fax:954-248-1974
Practice Address - Street 1:2645 EXECUTIVE PARK DR
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33331-3624
Practice Address - Country:US
Practice Address - Phone:954-644-2645
Practice Address - Fax:954-248-1974
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5276235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8850445Medicaid