Healthcare Provider Details

I. General information

NPI: 1215912662
Provider Name (Legal Business Name): JACQUELYN A SCHMIDA CCC SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2005
Last Update Date: 01/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 CALEDONIA ST
LA CROSSE WI
54603-2616
US

IV. Provider business mailing address

901 CALEDONIA ST
LA CROSSE WI
54603-2616
US

V. Phone/Fax

Practice location:
  • Phone: 608-785-4100
  • Fax: 608-785-4101
Mailing address:
  • Phone: 608-785-4100
  • Fax: 608-785-4101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number651
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: