Provider Demographics
NPI:1093349268
Name:SHIELDS, JESSICA (SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SHIELDS
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 1:1032 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FISHKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12524-3503
Mailing Address - Country:US
Mailing Address - Phone:845-897-3330
Mailing Address - Fax:
Practice Address - Street 1:1032 MAIN ST
Practice Address - Street 2:
Practice Address - City:FISHKILL
Practice Address - State:NY
Practice Address - Zip Code:12524-3503
Practice Address - Country:US
Practice Address - Phone:845-897-3330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-26
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
KS3577235Z00000X
NY031203235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician