Provider Demographics
NPI:1538914718
Name:COULTAS, JACIE ELAINE (MS, CF-SLP)
Entity type:Individual
Prefix:MISS
First Name:JACIE
Middle Name:ELAINE
Last Name:COULTAS
Suffix:
Gender:
Credentials: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 1:5604A VIRGINIA BEACH BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-5681
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5604A VIRGINIA BEACH BLVD STE 101
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-5681
Practice Address - Country:US
Practice Address - Phone:757-455-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-20
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202011850235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist