=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124495627
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRYSTAL JAQUISH M.A., SLP-CCC, TSLD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2015
-----------------------------------------------------
Last Update Date | 12/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8566 U.S. ROUTE 9
-----------------------------------------------------
City | LEWIS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-565-7036
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28 HILTON TER
-----------------------------------------------------
City | WILLSBORO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12996-4042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 968174151
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 027551
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------