Provider Demographics
NPI:1003430349
Name:BACON, JASMINE (MS-SLP, CCC)
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:BACON
Suffix:
Gender:F
Credentials:MS-SLP, CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2409 E 19TH ST
Mailing Address - Street 2:
Mailing Address - City:SIGNAL HILL
Mailing Address - State:CA
Mailing Address - Zip Code:90755-6001
Mailing Address - Country:US
Mailing Address - Phone:949-291-8282
Mailing Address - Fax:
Practice Address - Street 1:3722 KATELLA AVE STE C
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3102
Practice Address - Country:US
Practice Address - Phone:949-291-8282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-02
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14507235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist