1689737421 NPI number — MRS. JACQULYN BRECKOW SLP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689737421 NPI number — MRS. JACQULYN BRECKOW SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRECKOW
Provider First Name:
JACQULYN
Provider Middle Name:
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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689737421
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
06/18/2010
NPI Reactivation Date:
11/02/2012

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
690 E WARNER RD
Provider Second Line Business Mailing Address:
SUITE #105
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85296-3054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-820-6366
Provider Business Mailing Address Fax Number:
480-820-0462

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
690 E WARNER RD
Provider Second Line Business Practice Location Address:
SUITE #105
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85296-3054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-820-6366
Provider Business Practice Location Address Fax Number:
480-820-0462
Provider Enumeration Date:
12/19/2006

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:  TSLP4726 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 948317 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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