Basic Information
| Provider Information | |||||||||
| NPI: | 1457909830 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | LOIS REAGOR | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSP, CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | REAGOR | ||||||||
| OtherFirstName: | JACQUELINE | ||||||||
| OtherMiddleName: | LOIS | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1444 HERMITAGE LN | ||||||||
| Address2: | |||||||||
| City: | LADSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294563059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437545795 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9285 MEDICAL PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437978282 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2019 | ||||||||
| LastUpdateDate: | 11/03/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 7020 | SC | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.