MEDICARE: JACQUELINE CONNELL MS CCC-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

General Provider Information

NPI Number	:	1568786382
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE CONNELL MS CCC-SLP

Provider Business Mailing Address
First Line	:	450 SHORE RD
Second Line	:	APT 5B
City	:	LONG BEACH
State	:	NY
Zip	:	11561-5326
Country	:	US
Telephone Number	:	631-804-4503
Fax Number	:

Provider Business Practice Location Address
First Line	:	450 SHORE RD
Second Line	:	APT 5B
City	:	LONG BEACH
State	:	NY
Zip	:	11561-5326
Country	:	US
Telephone Number	:	631-804-4503
Fax Number	:

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

Provider Enumeration Date	:	03/23/2010
Last Update Date	:	01/29/2021

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Directions to “ JACQUELINE CONNELL MS CCC-SLP” Practice Location

Language	Start Address	Practice Location

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