Provider Demographics
NPI:1124189915
Name:OLDER, JESSICA ANN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:OLDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15143 N CHERRY CT
Mailing Address - Street 2:
Mailing Address - City:PARKVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64152-1640
Mailing Address - Country:US
Mailing Address - Phone:217-276-5377
Mailing Address - Fax:
Practice Address - Street 1:15143 N CHERRY CT
Practice Address - Street 2:
Practice Address - City:PARKVILLE
Practice Address - State:MO
Practice Address - Zip Code:64152-1640
Practice Address - Country:US
Practice Address - Phone:217-276-5377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009014885235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist