Provider Demographics
NPI:1992254262
Name:WEDDLE, JACQUIE
Entity type:Individual
Prefix:
First Name:JACQUIE
Middle Name:
Last Name:WEDDLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W KNOX AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-4323
Mailing Address - Country:US
Mailing Address - Phone:150-354-6523
Mailing Address - Fax:509-354-6400
Practice Address - Street 1:1300 W KNOX AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-4323
Practice Address - Country:US
Practice Address - Phone:150-935-4652
Practice Address - Fax:509-354-6400
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60651058235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMEDICAIDMedicaid