Provider Demographics
NPI:1316515752
Name:JACQUEZ-JARAMILLO, SHANNON NICOLE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICOLE
Last Name:JACQUEZ-JARAMILLO
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 AMBROSE LN
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-4443
Mailing Address - Country:US
Mailing Address - Phone:949-683-8525
Mailing Address - Fax:
Practice Address - Street 1:624 AMBROSE LN
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-4443
Practice Address - Country:US
Practice Address - Phone:949-683-8525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-13
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15506235Z00000X
CA33609235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist