Provider Demographics
NPI:1538879010
Name:LAVENDER, JACQUELYN SUZANNE (SLP)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:SUZANNE
Last Name:LAVENDER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2746 BERKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:WINDER
Mailing Address - State:GA
Mailing Address - Zip Code:30680-6121
Mailing Address - Country:US
Mailing Address - Phone:770-362-6939
Mailing Address - Fax:
Practice Address - Street 1:8770 GLASGOW POINTE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-6606
Practice Address - Country:US
Practice Address - Phone:440-497-8499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-25
Last Update Date:2022-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005556235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty