Provider Demographics
NPI:1104474089
Name:DEWAAL, JACQUELYN S (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:S
Last Name:DEWAAL
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 1:1096 34TH ST
Mailing Address - Street 2:
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-9305
Mailing Address - Country:US
Mailing Address - Phone:269-365-3279
Mailing Address - Fax:269-781-9290
Practice Address - Street 1:1096 34TH ST
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-9305
Practice Address - Country:US
Practice Address - Phone:269-365-3279
Practice Address - Fax:269-781-9290
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101006233235Z00000X
MI7101006797235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist