1417589060 NPI number — MRS. JACQUELYN BROOKE LETHERMAN SLP

Table of content: MRS. JACQUELYN BROOKE LETHERMAN SLP (NPI 1417589060)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417589060 NPI number — MRS. JACQUELYN BROOKE LETHERMAN SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LETHERMAN
Provider First Name:
JACQUELYN
Provider Middle Name:
BROOKE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NONTE
Provider Other First Name:
JACQUELYN
Provider Other Middle Name:
BROOKE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
SLP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1417589060
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 TERRACE DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOOGOOTEE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47553
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-296-1350
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 TERRACE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOOGOOTEE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47553-2207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-296-1350
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/11/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  22007261A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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