Basic Information
| Provider Information | |||||||||
| NPI: | 1265835771 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROCKWELL | ||||||||
| FirstName: | JEANNETTE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WYCKOFF | ||||||||
| OtherFirstName: | JEANNETTE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 151 N SUNRISE AVE | ||||||||
| Address2: | SUITE 1105 | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956612924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167718255 | ||||||||
| FaxNumber: | 9167718211 | ||||||||
| Practice Location | |||||||||
| Address1: | 151 N SUNRISE AVE | ||||||||
| Address2: | SUITE 1105 | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956612924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167718255 | ||||||||
| FaxNumber: | 9167718211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2014 | ||||||||
| LastUpdateDate: | 09/29/2014 | ||||||||
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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 | 18814 | CA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.