1740454925 NPI number — JESSICA LYNN CUNNINGHAM M.S., CCC-SLP

Table of content: JESSICA LYNN CUNNINGHAM M.S., CCC-SLP (NPI 1740454925)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740454925 NPI number — JESSICA LYNN CUNNINGHAM M.S., CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CUNNINGHAM
Provider First Name:
JESSICA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S., CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740454925
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1102 WINKLER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KILLEEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76542-6249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-634-8505
Provider Business Mailing Address Fax Number:
254-519-3477

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
763 JOHNSONBURG RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT MARYS
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15857-3417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-788-8311
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/17/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  505-SLP , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: 106370 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: 2202005440 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: PASL007942 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 13967076065 . This is a "MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1396706065 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 192597 . This is a "BC/BS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".