Provider Demographics
NPI:1306609797
Name:JACQUOT, MATTHEW THOMAS
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:THOMAS
Last Name:JACQUOT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22722 LAMBERT ST STE 611
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-1633
Mailing Address - Country:US
Mailing Address - Phone:949-429-8161
Mailing Address - Fax:
Practice Address - Street 1:22722 LAMBERT ST STE 611
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-1633
Practice Address - Country:US
Practice Address - Phone:949-429-8161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80982355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant