Provider Demographics
NPI:1881888790
Name:SMITH, JACQUELINE LEE (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:LEE
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4222 E VEST AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-6144
Mailing Address - Country:US
Mailing Address - Phone:630-631-8343
Mailing Address - Fax:
Practice Address - Street 1:140 S GILBERT RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-1016
Practice Address - Country:US
Practice Address - Phone:480-497-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-04
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP5393235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist