1134339625 NPI number — MRS. JACKIE DEESE SPEECH THERAPIST

Table of content: MRS. JACKIE DEESE SPEECH THERAPIST (NPI 1134339625)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134339625 NPI number — MRS. JACKIE DEESE SPEECH THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEESE
Provider First Name:
JACKIE
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
SPEECH THERAPIST
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:
1134339625
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1288
Provider Second Line Business Mailing Address:
580 FARRINGDOM STREET
Provider Business Mailing Address City Name:
LUMBERTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28359
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-671-9629
Provider Business Mailing Address Fax Number:
910-671-9630

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
580 FARRINGDOM STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUMBERTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28358
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-671-9629
Provider Business Practice Location Address Fax Number:
910-671-9630
Provider Enumeration Date:
05/23/2007

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:  6141 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7412452 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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