Provider Demographics
NPI:1861531188
Name:THEECK, JACLYN LOUISE (MA CCC-SLP)
Entity type:Individual
Prefix:MISS
First Name:JACLYN
Middle Name:LOUISE
Last Name:THEECK
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 SUN TERRACE CT
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33403-1188
Mailing Address - Country:US
Mailing Address - Phone:561-776-8612
Mailing Address - Fax:
Practice Address - Street 1:301 SUN TERRACE CT
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33403-1188
Practice Address - Country:US
Practice Address - Phone:561-776-8612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 7555235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8895171-00Medicaid