Provider Demographics
NPI:1215962691
Name:BEATTY, JACKIE ELAINE (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:ELAINE
Last Name:BEATTY
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 1:750 LAKESHORE DR.
Mailing Address - Street 2:
Mailing Address - City:PIERSON
Mailing Address - State:FL
Mailing Address - Zip Code:32180
Mailing Address - Country:US
Mailing Address - Phone:321-231-2962
Mailing Address - Fax:888-845-9818
Practice Address - Street 1:750 LAKESHORE DR.
Practice Address - Street 2:
Practice Address - City:PIERSON
Practice Address - State:FL
Practice Address - Zip Code:32180
Practice Address - Country:US
Practice Address - Phone:321-231-2962
Practice Address - Fax:888-845-9818
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8761222Q00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000476900Medicaid
FL890711100Medicaid