Provider Demographics
NPI:1417589060
Name:LETHERMAN, JACQUELYN BROOKE (SLP)
Entity type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:BROOKE
Last Name:LETHERMAN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:MISS
Other - First Name:JACQUELYN
Other - Middle Name:BROOKE
Other - Last Name:NONTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:101 TERRACE DRIVE
Mailing Address - Street 2:
Mailing Address - City:LOOGOOTEE
Mailing Address - State:IN
Mailing Address - Zip Code:47553
Mailing Address - Country:US
Mailing Address - Phone:812-296-1350
Mailing Address - Fax:
Practice Address - Street 1:101 TERRACE DR
Practice Address - Street 2:
Practice Address - City:LOOGOOTEE
Practice Address - State:IN
Practice Address - Zip Code:47553-2207
Practice Address - Country:US
Practice Address - Phone:812-296-1350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-11
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22007261A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist