Provider Demographics
NPI:1104105469
Name:TOMALO, JACLYN MARIE (AUD)
Entity type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:MARIE
Last Name:TOMALO
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 PARADISE POINT WAY
Mailing Address - Street 2:
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731-4302
Mailing Address - Country:US
Mailing Address - Phone:917-517-0764
Mailing Address - Fax:
Practice Address - Street 1:500 LAKEHURST RD
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-8064
Practice Address - Country:US
Practice Address - Phone:732-914-8022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YA00079800231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist