Provider Demographics
NPI:1255999322
Name:DITSLEAR, JACQUELINE NICOLE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:NICOLE
Last Name:DITSLEAR
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1628 HOYT AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46203-1205
Mailing Address - Country:US
Mailing Address - Phone:317-869-9784
Mailing Address - Fax:
Practice Address - Street 1:1628 HOYT AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46203-1205
Practice Address - Country:US
Practice Address - Phone:317-869-9784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-03
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN46003526A235Z00000X
IN22007531A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty