Provider Demographics
NPI:1225392392
Name:ABAWAG, JESSICA FAIRBANKS (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:FAIRBANKS
Last Name:ABAWAG
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:FAIRBANKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2601 70TH AVE W STE E
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-5430
Mailing Address - Country:US
Mailing Address - Phone:253-212-3502
Mailing Address - Fax:888-972-1827
Practice Address - Street 1:2601 70TH AVE W STE E
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-5430
Practice Address - Country:US
Practice Address - Phone:253-212-3502
Practice Address - Fax:888-972-1827
Is Sole Proprietor?:No
Enumeration Date:2012-07-03
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20826235Z00000X
WALL60654675235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2069268Medicaid