Provider Demographics
NPI:1124321740
Name:SANDBERG, JACQUELINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:SANDBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:SANDBERG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:729 W 186TH ST APT 1C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-8506
Mailing Address - Country:US
Mailing Address - Phone:212-928-6901
Mailing Address - Fax:
Practice Address - Street 1:729 W 186TH ST APT 1C
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-8506
Practice Address - Country:US
Practice Address - Phone:212-928-6901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-21
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016245-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist