Provider Demographics
NPI:1972810224
Name:GATES, JACQUELYN MICHELLE (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:MICHELLE
Last Name:GATES
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2780 W 56TH AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80221
Mailing Address - Country:US
Mailing Address - Phone:720-884-6798
Mailing Address - Fax:
Practice Address - Street 1:7000 BROADWAY
Practice Address - Street 2:SUITE 208
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80221
Practice Address - Country:US
Practice Address - Phone:303-327-9738
Practice Address - Fax:884-472-2799
Is Sole Proprietor?:No
Enumeration Date:2010-09-08
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP 18382235Z00000X
CO0002430235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO59855037Medicaid