Provider Demographics
NPI:1003940933
Name:JAESAN PC
Entity Type:Organization
Organization Name:JAESAN PC
Other - Org Name:SPEECHWORKS THERAPY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAI
Authorized Official - Middle Name:ANE
Authorized Official - Last Name:JERRELL
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:980-237-6226
Mailing Address - Street 1:3116 MILTON RD STE F
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-5079
Mailing Address - Country:US
Mailing Address - Phone:980-237-6226
Mailing Address - Fax:980-237-6288
Practice Address - Street 1:3116 MILTON RD STE F
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-5079
Practice Address - Country:US
Practice Address - Phone:980-237-6226
Practice Address - Fax:980-237-6288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5842235Z00000X
NC6278235Z00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7411868Medicaid
NC7212056Medicaid