Provider Demographics
NPI:1114199957
Name:CARMODY, JAIME L (MS,CCC-A)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:L
Last Name:CARMODY
Suffix:
Gender:F
Credentials:MS,CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 OLD DES PERES RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1865
Mailing Address - Country:US
Mailing Address - Phone:314-722-2957
Mailing Address - Fax:314-729-0101
Practice Address - Street 1:12380 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-6443
Practice Address - Country:US
Practice Address - Phone:314-729-0077
Practice Address - Fax:314-729-0101
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-01
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006006300231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO138830003OtherMEDICARE PTAN