Provider Demographics
NPI:1801062625
Name:DEMETROFF, JACQUELYN R (MA)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:R
Last Name:DEMETROFF
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 FOOTHILL BLVD
Mailing Address - Street 2:SUITE #2
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91011-2194
Mailing Address - Country:US
Mailing Address - Phone:818-952-1130
Mailing Address - Fax:818-952-1134
Practice Address - Street 1:5160 VINELAND AVE STE 101C
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91601-3888
Practice Address - Country:US
Practice Address - Phone:818-853-0165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU2479237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter