=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376097816
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACLYN DIANA LORRAINE M.A., CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2016
-----------------------------------------------------
Last Update Date | 01/31/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2525C LEBANON PIKE STE 102
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37214-2473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-669-0761
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1817 W MORSE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60626-3108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-650-3369
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 146017873
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------