Provider Demographics
NPI:1801326913
Name:STALEY, JACLYN (CCC-SLP)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:STALEY
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 1:2500 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-3402
Mailing Address - Country:US
Mailing Address - Phone:304-264-1000
Mailing Address - Fax:
Practice Address - Street 1:2500 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-3402
Practice Address - Country:US
Practice Address - Phone:304-264-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05467235Z00000X
WVSLP-1772235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist