Provider Demographics
NPI:1194165969
Name:PATEROS, JACLYN
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:PATEROS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1354 PICKWICK CT
Mailing Address - Street 2:
Mailing Address - City:NAPPANEE
Mailing Address - State:IN
Mailing Address - Zip Code:46550-1193
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1354 PICKWICK CT
Practice Address - Street 2:
Practice Address - City:NAPPANEE
Practice Address - State:IN
Practice Address - Zip Code:46550-1193
Practice Address - Country:US
Practice Address - Phone:574-354-0025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22006037A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist