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1952441602 NPI number — JACKIE LYNN MATHIESEN M.S. CCC-SLP

NPI Number: 1952441602
Health Care Provider/Practitioner: JACKIE LYNN MATHIESEN M.S. CCC-SLP

Information about “1952441602” NPI (JACKIE LYNN MATHIESEN M.S. CCC-SLP) exists in 1952441602 in HTML format HTML  |  1952441602 in plain Text format TXT  |  1952441602 in PDF (Portable Document Format) PDF  |  1952441602 in an XML format XML  formats.

NPI Number : 1952441602 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1952441602",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "MATHIESEN",
    "FirstName": "JACKIE",
    "MiddleName": "LYNN",
    "NamePrefix": "MRS.",
    "NameSuffix": null,
    "Credential": "M.S. CCC-SLP",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": "JOHNSTON",
    "OtherFirstName": "JACKIE",
    "OtherMiddleName": "LYNN",
    "OtherNamePrefix": "MISS",
    "OtherNameSuffix": null,
    "OtherCredential": "M.S. CCC-SLP",
    "OtherLastNameTypeCode": "1",
    "FirstLineMailingAddress": "14408 W DESERT COVE RD",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "SURPRISE",
    "MailingAddressStateName": "AZ",
    "MailingAddressPostalCode": "85379-4334",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": null,
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "12409 W INDIAN SCHOOL RD STE C306",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "AVONDALE",
    "PracticeLocationAddressStateName": "AZ",
    "PracticeLocationAddressPostalCode": "85323-9508",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "623-935-6040",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "02/08/2007",
    "LastUpdateDate": "07/08/2007",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "235Z00000X",
        "TaxonomyName": "Speech-Language Pathologist",
        "LicenseNumber": "SLP4480",
        "LicenseNumberStateCode": "AZ",
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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