Provider Demographics
NPI:1326242652
Name:PROVOST, JESSICA E (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:E
Last Name:PROVOST
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 1:6033 LARBOARD DR.
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27539-4115
Mailing Address - Country:US
Mailing Address - Phone:919-329-7733
Mailing Address - Fax:
Practice Address - Street 1:6033 LARBOARD DR.
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27539-4115
Practice Address - Country:US
Practice Address - Phone:919-329-7733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7545235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7412731Medicaid