Provider Demographics
NPI:1992243620
Name:JACKOVITZ, DANIELLE FERNANDA (MS)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:FERNANDA
Last Name:JACKOVITZ
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25117 SW PARKWAY AVE
Mailing Address - Street 2:STE D
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-9697
Mailing Address - Country:US
Mailing Address - Phone:971-224-2040
Mailing Address - Fax:
Practice Address - Street 1:25117 SW PARKWAY AVE
Practice Address - Street 2:STE D
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-9697
Practice Address - Country:US
Practice Address - Phone:971-224-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-01
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist