Healthcare Provider Details

I. General information

NPI: 1912570219
Provider Name (Legal Business Name): JACQUELINE MANSARAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2021
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 E RAY RD STE 101A
PHOENIX AZ
85044-4707
US

IV. Provider business mailing address

2339 E GENEVA DR
TEMPE AZ
85282-4146
US

V. Phone/Fax

Practice location:
  • Phone: 480-704-5954
  • Fax:
Mailing address:
  • Phone: 713-474-6598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP17250
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: