Provider Demographics
NPI:1215184775
Name:DWYER, JESSICA ROSE (MA,CCC-A)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ROSE
Last Name:DWYER
Suffix:
Gender:F
Credentials:MA,CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 U ST
Mailing Address - Street 2:
Mailing Address - City:LAKE LOTAWANA
Mailing Address - State:MO
Mailing Address - Zip Code:64086-9755
Mailing Address - Country:US
Mailing Address - Phone:660-747-5444
Mailing Address - Fax:660-747-5481
Practice Address - Street 1:706 N BURKARTH RD
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093-9303
Practice Address - Country:US
Practice Address - Phone:660-747-5444
Practice Address - Fax:660-747-5481
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-26
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003027555231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist