Provider Demographics
NPI:1699085837
Name:CULLEN, JACQUELINE (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:CULLEN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 RICHMOND CIR
Mailing Address - Street 2:
Mailing Address - City:CHITTENANGO
Mailing Address - State:NY
Mailing Address - Zip Code:13037-9442
Mailing Address - Country:US
Mailing Address - Phone:315-687-9392
Mailing Address - Fax:
Practice Address - Street 1:8199 E SENECA TPKE
Practice Address - Street 2:
Practice Address - City:MANLIUS
Practice Address - State:NY
Practice Address - Zip Code:13104-2101
Practice Address - Country:US
Practice Address - Phone:315-692-1203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011245-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
12010185OtherAMERICAN SPEECH LANGUAGE HEARING ASSOCIATION
NY011245-1OtherNEW YORK STATE LICENSE