Provider Demographics
NPI:1073801098
Name:THOMAS, JESSICA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:THOMAS
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 1:1176 WOODBRIDGE LN SE
Mailing Address - Street 2:
Mailing Address - City:BOLIVIA
Mailing Address - State:NC
Mailing Address - Zip Code:28422-8969
Mailing Address - Country:US
Mailing Address - Phone:910-612-1002
Mailing Address - Fax:910-755-5864
Practice Address - Street 1:4501 MAIN ST
Practice Address - Street 2:SUITE 5
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-4589
Practice Address - Country:US
Practice Address - Phone:910-612-1002
Practice Address - Fax:910-755-5864
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-11
Last Update Date:2012-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6026235Z00000X
SC3389235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist