1932693694 NPI number — JESSICA ANN WHITE M.A CCC-SLP

Table of content: JESSICA ANN WHITE M.A CCC-SLP (NPI 1932693694)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932693694 NPI number — JESSICA ANN WHITE M.A CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITE
Provider First Name:
JESSICA
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A 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:
1932693694
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 PORTAGE WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLONA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61241-8642
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6210 GIBSON LN APT 4306
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEXARKANA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75503-1253
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-572-4192
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/17/2018

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200101 . This is a "ARKANSAS BOARD OF EXAMINERS SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY LICENSE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 113258 . This is a "TEXAS DEPARTMENT OF LICENSING AND REGULATION" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 14110526 . This is a "AMERICAN SPEECH-LANGUAGE-HEARING ASSOCIATION" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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