Provider Demographics
NPI:1699434639
Name:ST MARIE, JACKIE (SLP)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:ST MARIE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:DECIANNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:25117 SW PARKWAY AVE STE D
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-9697
Mailing Address - Country:US
Mailing Address - Phone:971-364-0611
Mailing Address - Fax:971-364-0610
Practice Address - Street 1:1014 BURRELL AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-5472
Practice Address - Country:US
Practice Address - Phone:208-743-4558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist