MEDICARE: JACQUELINE PRUITT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	1001440500	WI

General Provider Information

NPI Number	:	1194658245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE PRUITT

Provider Business Mailing Address
First Line	:	3546 OSBORNE BLVD
Second Line	:
City	:	RACINE
State	:	WI
Zip	:	53405-2031
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3501 KINZIE AVE
Second Line	:
City	:	RACINE
State	:	WI
Zip	:	53405-2438
Country	:	US
Telephone Number	:	262-664-8150
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2026
Last Update Date	:	06/08/2026

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Directions to “ JACQUELINE PRUITT ” Practice Location

Language	Start Address	Practice Location

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