MEDICARE: JACLYN WEISS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	4366	SC
2	235Z00000X	Speech-Language Pathologist	7860	NC
3	235Z00000X	Speech-Language Pathologist	016317-1	NY

General Provider Information

NPI Number	:	1174777171
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACLYN WEISS

Provider Business Mailing Address
First Line	:	6709 KACI LN
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29707-3201
Country	:	US
Telephone Number	:	803-548-0369
Fax Number	:

Provider Business Practice Location Address
First Line	:	6709 KACI LN
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29707-3201
Country	:	US
Telephone Number	:	803-548-0369
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/05/2008
Last Update Date	:	11/05/2008

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Directions to “ JACLYN WEISS ” Practice Location

Language	Start Address	Practice Location

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