Provider Demographics
NPI:1053440693
Name:WOOTEN, JANICE JORDAN (MS CCC SLP)
Entity Type:Individual
Prefix:MRS
First Name:JANICE
Middle Name:JORDAN
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3712 TRACE DR W
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-8347
Mailing Address - Country:US
Mailing Address - Phone:252-291-2137
Mailing Address - Fax:252-237-8313
Practice Address - Street 1:3712 TRACE DR W
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-8347
Practice Address - Country:US
Practice Address - Phone:252-291-2137
Practice Address - Fax:252-237-8313
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6810235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7412313Medicaid