Provider Demographics
NPI:1841010840
Name:GANNON, JACLYN
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:GANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:
Other - Last Name:KINSMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12505 BENTLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-1223
Mailing Address - Country:US
Mailing Address - Phone:567-239-2514
Mailing Address - Fax:
Practice Address - Street 1:6622 AVALON FOREST DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2804
Practice Address - Country:US
Practice Address - Phone:567-239-2514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist