Healthcare Provider Details

I. General information

NPI: 1811510878
Provider Name (Legal Business Name): JACQUELYN KIELB MA, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2020
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44225 W 12 MILE RD STE C-106
NOVI MI
48377-2640
US

IV. Provider business mailing address

44225 W 12 MILE RD STE C-106
NOVI MI
48377-2640
US

V. Phone/Fax

Practice location:
  • Phone: 248-277-3005
  • Fax:
Mailing address:
  • Phone: 248-277-3005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7152000316
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101008374
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: