Provider Demographics
NPI:1255859161
Name:WARREN, JESSICA RENAE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RENAE
Last Name:WARREN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5315 S BROADWAY AVE APT 20
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-3749
Mailing Address - Country:US
Mailing Address - Phone:903-426-6358
Mailing Address - Fax:
Practice Address - Street 1:8001 S US HIGHWAY 75
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75090-5707
Practice Address - Country:US
Practice Address - Phone:903-532-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110004235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist