Basic Information
| Provider Information | |||||||||
| NPI: | 1104387703 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORTNER | ||||||||
| FirstName: | JACQUELYN | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | M.A. CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 63 LARKFIELD MAPLES CT | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954031486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308593117 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3265 BIDDLE RD | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975044122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418164747 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2019 | ||||||||
| LastUpdateDate: | 03/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 27301 | CA | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 016472 | OR | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.