Provider Demographics
NPI:1073130126
Name:MYERS, JESSICA (SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MYERS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2812 W LOST RAPIDS DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6197
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12222 W BRIDGER BAY DR
Practice Address - Street 2:
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669-5081
Practice Address - Country:US
Practice Address - Phone:208-391-2773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-05
Last Update Date:2020-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTSLP-4363235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist