Provider Demographics
NPI:1902342090
Name:COMBS, JACLYN ASHLEY
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:ASHLEY
Last Name:COMBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5176 WRIGHTSBORO RD
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-2802
Mailing Address - Country:US
Mailing Address - Phone:309-732-6760
Mailing Address - Fax:
Practice Address - Street 1:5176 WRIGHTSBORO RD
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813-2802
Practice Address - Country:US
Practice Address - Phone:309-732-6760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-12
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA095143235Z00000X
IL242004004235Z00000X
GASLP010910235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist