MEDICARE: JACQUELYN M. SEIDLER SLP

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	5263	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5263-154	OTHER	WI	WI DEPARTMENT OF SAFETY & PROFESSIONAL SERVICES

General Provider Information

NPI Number	:	1538739099
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELYN M. SEIDLER SLP

Provider Business Mailing Address
First Line	:	2730 N ROEMER RD
Second Line	:
City	:	APPLETON
State	:	WI
Zip	:	54911-8628
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2730 N ROEMER RD
Second Line	:
City	:	APPLETON
State	:	WI
Zip	:	54911-8628
Country	:	US
Telephone Number	:	920-749-5859
Fax Number	:

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

Provider Enumeration Date	:	06/28/2021
Last Update Date	:	11/17/2022

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