Basic Information
| Provider Information | |||||||||
| NPI: | 1699434639 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ST MARIE | ||||||||
| FirstName: | JACKIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DECIANNE | ||||||||
| OtherFirstName: | JACKIE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 25117 SW PARKWAY AVE STE D | ||||||||
| Address2: | |||||||||
| City: | WILSONVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970709697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9713640611 | ||||||||
| FaxNumber: | 9713640610 | ||||||||
| Practice Location | |||||||||
| Address1: | 1014 BURRELL AVE | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835015472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087434558 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2021 | ||||||||
| LastUpdateDate: | 12/16/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.