Provider Demographics
NPI:1386980761
Name:JACKY, WHITNEY KATHLEEN (AUD)
Entity type:Individual
Prefix:
First Name:WHITNEY
Middle Name:KATHLEEN
Last Name:JACKY
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:WHITNEY
Other - Middle Name:KATHLEEN
Other - Last Name:OTTESON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:104B E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-1924
Mailing Address - Country:US
Mailing Address - Phone:509-876-0555
Mailing Address - Fax:509-876-0556
Practice Address - Street 1:104B E MAIN ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-1924
Practice Address - Country:US
Practice Address - Phone:509-876-0555
Practice Address - Fax:509-876-0556
Is Sole Proprietor?:No
Enumeration Date:2012-12-12
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60285618231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1336318310Medicaid