Basic Information
| Provider Information | |||||||||
| NPI: | 1689871733 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JAGELMAN | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | LOVEJOY | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | M.ED. CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 428 NE 12TH AVE | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333011238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9548153542 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1401 S FEDERAL HWY | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333162619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547281098 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2007 | ||||||||
| LastUpdateDate: | 05/01/2015 | ||||||||
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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 | SA 9056 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 222Q00000X | SA9056 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
ID Information
| ID | Type | State | Issuer | Description | 008335100 | 05 | FL | MEDICAID |