Healthcare Provider Details

I. General information

NPI: 1831053511
Provider Name (Legal Business Name): JAQUELINE SOFIA CEBALLOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 HURRICANE SHOALS RD NE STE 2300
LAWRENCEVILLE GA
30043-4871
US

IV. Provider business mailing address

625 CLEARWATER PL
LAWRENCEVILLE GA
30044-6834
US

V. Phone/Fax

Practice location:
  • Phone: 470-323-6711
  • Fax: 478-575-2359
Mailing address:
  • Phone: 404-944-2477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLPA000601
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: