Provider Demographics
NPI:1073760914
Name:BLACK, JADE GALLOWAY (MCD,CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JADE
Middle Name:GALLOWAY
Last Name:BLACK
Suffix:
Gender:F
Credentials:MCD,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 BENT WILLOW WAY
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29642
Mailing Address - Country:US
Mailing Address - Phone:864-630-8188
Mailing Address - Fax:
Practice Address - Street 1:205 B CONCORD ROAD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621
Practice Address - Country:US
Practice Address - Phone:864-630-8188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-21
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3922235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist