Provider Demographics
NPI:1124293774
Name:ROLLINS, JACQUELINE KRISTINE (SLP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:KRISTINE
Last Name:ROLLINS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 BYRD AVE
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-4015
Mailing Address - Country:US
Mailing Address - Phone:920-725-7869
Mailing Address - Fax:
Practice Address - Street 1:125 BYRD AVE
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-4015
Practice Address - Country:US
Practice Address - Phone:920-725-7869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42589100Medicaid