Provider Demographics
NPI:1902584063
Name:JACKLOSKI, SHELBY LYNN (MM, MS, CF-SLP)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:LYNN
Last Name:JACKLOSKI
Suffix:
Gender:F
Credentials:MM, MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15280 NW 79TH CT STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-5873
Mailing Address - Country:US
Mailing Address - Phone:305-558-3724
Mailing Address - Fax:786-907-4485
Practice Address - Street 1:6705 S RED RD STE 508
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-3644
Practice Address - Country:US
Practice Address - Phone:516-996-7386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ11299235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist