Provider Demographics
NPI:1750427639
Name:JACQUET, TARA A (MS CCC SLP)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:A
Last Name:JACQUET
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:RUMMERY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:75 W COMMERCIAL ST
Mailing Address - Street 2:NORTHEAST HEARING AND SPEECH, SUITE 205
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-4797
Mailing Address - Country:US
Mailing Address - Phone:207-874-1065
Mailing Address - Fax:207-874-1068
Practice Address - Street 1:75 W COMMERCIAL ST
Practice Address - Street 2:NORTHEAST HEARING AND SPEECH, SUITE 205
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4797
Practice Address - Country:US
Practice Address - Phone:207-874-1065
Practice Address - Fax:207-874-1068
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP774235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME024434OtherANTHEM BCBS
ME269440099Medicaid