Provider Demographics
NPI:1023684537
Name:GAVIN, JACKLYN S
Entity type:Individual
Prefix:
First Name:JACKLYN
Middle Name:S
Last Name:GAVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 WOODCLIFF RD
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:MA
Mailing Address - Zip Code:02343-1130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:80 WASHINGTON ST STE P55
Practice Address - Street 2:
Practice Address - City:NORWELL
Practice Address - State:MA
Practice Address - Zip Code:02061-1742
Practice Address - Country:US
Practice Address - Phone:781-290-3886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-03
Last Update Date:2023-09-06
Deactivation Date:2023-08-18
Deactivation Code:
Reactivation Date:2023-09-06
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty