Provider Demographics
NPI:1356489553
Name:MOSS, JESSIE A (SLP)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:A
Last Name:MOSS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16357 AURORA AVE N
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-5651
Mailing Address - Country:US
Mailing Address - Phone:206-542-3103
Mailing Address - Fax:
Practice Address - Street 1:16357 AURORA AVE N
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133-5651
Practice Address - Country:US
Practice Address - Phone:206-542-3103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00003350235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist