Provider Demographics
NPI:1871975391
Name:ANDERSON, JACQUELYN
Entity type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JACQUELYN
Other - Middle Name:
Other - Last Name:LERECHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4560 SOUTH BLVD STE 310
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-1160
Mailing Address - Country:US
Mailing Address - Phone:757-490-3223
Mailing Address - Fax:757-490-2936
Practice Address - Street 1:4560 SOUTH BLVD STE 310
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-1160
Practice Address - Country:US
Practice Address - Phone:757-490-3223
Practice Address - Fax:757-490-2936
Is Sole Proprietor?:No
Enumeration Date:2015-06-20
Last Update Date:2015-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202007712235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist