Healthcare Provider Details

I. General information

NPI: 1558762294
Provider Name (Legal Business Name): JUDITH YACKS SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2014
Last Update Date: 09/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 E MAIN ST
AMELIA OH
45102-1943
US

IV. Provider business mailing address

5 E MAIN ST
AMELIA OH
45102-1943
US

V. Phone/Fax

Practice location:
  • Phone: 513-943-3813
  • Fax: 513-943-3642
Mailing address:
  • Phone: 513-943-3813
  • Fax: 513-943-3642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP1048
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: