Provider Demographics
NPI:1245418623
Name:WATERMAN, JESSICA LEE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:WATERMAN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14018 IMAGE LAKE CT
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1823
Mailing Address - Country:US
Mailing Address - Phone:239-823-2252
Mailing Address - Fax:
Practice Address - Street 1:9350 CAMELOT DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-7980
Practice Address - Country:US
Practice Address - Phone:239-337-5437
Practice Address - Fax:239-332-1800
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-07
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6644235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist