Provider Demographics
NPI:1366444846
Name:NIEDERKORN, JESSICA (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:NIEDERKORN
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4034 ROUNDTOP CIR
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:GA
Mailing Address - Zip Code:31069-7806
Mailing Address - Country:US
Mailing Address - Phone:478-718-0573
Mailing Address - Fax:
Practice Address - Street 1:4034 ROUNDTOP CIR
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:GA
Practice Address - Zip Code:31069-7806
Practice Address - Country:US
Practice Address - Phone:478-718-0573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2022-06-30
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-04-12
Provider Licenses
StateLicense IDTaxonomies
GASLP005748235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA639235193KMedicaid